Causes of visual impairment in people aged 75 years and older in Britain: an add-on study to the MRC Trial of Assessment and Management of Older People in the Community

[Association between integrity of foveal photoreceptors and ultimate visual outcome in neovascular age-related macular degeneration]

PURPOSE

This study investigates the clinical features and outcome dimensions of neovascular age-related macular degeneration (nAMD).

MATERIAL AND METHODS

This retrospective study analyzed 80 subjects diagnosed with nAMD. The patients received successful treatment through intravitreal administration of anti-vascular endothelial growth factor (anti-VEGF) agents. The subjects were classified into three groups based on the final integrity of their inner segment/outer segment (IS/OS) layer of the retina, assessed using spectral-domain optical coherence tomography (SD-OCT). This classification helped to understand the extent of retinal damage and the progression of nAMD. The primary evaluation was to examine the association between final IS/OS integrity and final visual acuity in the groups. The study also evaluated foveal microstructures (choroidal neovascularization size, external limiting membrane, outer nuclear layer thickness, and central macular thickness) at the initial and final visits, and their relationships with final IS/OS integrity.

RESULTS

The study found a significant association (P<0.001) between final visual acuity and IS/OS integrity. The V group had the best visual acuity (0.12±0.09) compared to the P group (0.39±0.45) and I group (0.92±0.42). Improved visual acuity was strongly correlated with less disrupted IS/OS and ELM. Intact photoreceptor integrity was linked to preserved IS/OS and ELM, thinner CMT, and shorter CNV height before treatment. However, photoreceptor integrity was not significantly correlated with CMT, RPE regularity, or ONL thickness at the final examination, suggesting it may be independently affected by nAMD.

CONCLUSION

Final visual acuity in nAMD patients post-treatment was strongly linked to foveal photoreceptor integrity. Photoreceptor integrity correlated with initial visual acuity, CMT, ELM integrity, CNV height, and IS/OS layer integrity. These factors can predict visual outcomes after resolution of exudaiton.

Cataract surgery utilization in Parkinson's disease: the english longitudinal survey on ageing

PURPOSE

Older adults with Alzheimer's disease are less likely to be offered cataract surgery than the general population, but these disparities have not been examined in the context of other neurodegenerative disorders such as Parkinson's disease (PD).

METHODS

Using data from the English Longitudinal Study on Ageing (ELSA), an ongoing, longitudinal population-based survey of older adults in England, we examined the relationship between PD and cataract surgery among adults 50 and older. We used logistic regression to measure the association between PD and history of cataract surgery at baseline. In longitudinal analyses of subjects with no history of cataract surgery at time of enrollment, we used semiparametric, discrete-time proportional hazards models to model the incidence of cataract surgery as a function of PD and other time-dependent covariates. Models were adjusted for demographic variables, self-reported comorbidities, and measures of daily activity limitation.

RESULTS

We included data from 19,241 eligible ELSA respondents, of whom 231 (1.2%) reported a diagnosis of PD. PD was positively associated with a history of self-reported cataract surgery at baseline (OR 3.66, 95% CI: 2.55-5.26), but this did not remain significant after adjusting for confounders (OR 1.22, 95% CI: 0.75-1.98). Among subjects with no history of cataract surgery at baseline, PD was also not associated with incident cataract surgery (adjusted HR 1.32, 95% CI: 0.86-2.02).

CONCLUSION

Unlike Alzheimer's disease, people with PD were no less likely to receive cataract surgery compared to those without PD.

Visual impairment and the need for vision care services amongst older Finnish people receiving home care

AIM

This study aimed to describe visual performance and the need for vision care services among Finnish older people receiving home care. We evaluated the applicability of the Resident Assessment Instrument of Home Care (RAI HC) in identifying visual impairment (VI) and the need for vision care services among older people.

DESIGN

A descriptive quantitative, cross-sectional design.

METHODS

Visual impairment and the need for vision care services for older people receiving home care (N = 70) were determined by an optometrist's screening examination and vision assessment by home care workers using the RAI HC instrument. In this study, the definition of visual impairment was visual acuity (VA) <0.63 (logMAR >0.2).

RESULTS

According to the distance VA measurements, 41% of the participants showed VI (<0.63) of the better eye, while the RAI HC assessment revealed VI among 36% of the participants. The Kappa value for interrater reliability in classifying VI was 0.137. The optometrist's vision screening examination recognized a previously unknown and unmet need for vision care services more than twice as often as the RAI HC assessment.

Patterns of attendances to the hospital emergency eye care service: a multicentre study in England

BACKGROUND/OBJECTIVES

To characterise the patterns of presentation and diagnostic frequencies in Hospital Emergency Eye Care Services (HEECS) across 13 hospitals in England.

METHODS

Retrospective, cross-sectional, observational multi-centre (n = 13) study to assess HEECS attendances over a 28-day study period. Data derived included: number of consecutive attendances, patient demographics and diagnoses. Age and gender variations, the impact of day of the week on attendance patterns, diagnostic frequencies and estimates of the annual incidence and attendance rates were evaluated.

RESULTS

A total of 17,667 patient (mean ± standard deviation age = 49.6 ± 21.8 years) attendances were identified with an estimated HEECS annual new attendance rate of 31.0 per 1,000 population. Significantly more females (53%) than males (47%) attended HEECS (p < 0.001). Female attendances were 13% higher in those ≥50 years of age. Weekends were associated with a significant reduction in attendances compared to weekdays (χ2 = 6.94, p < 0.001). Among weekdays, Mondays and Fridays were associated with significantly higher attendances compared with midweek (χ2 = 2.20, p = 0.032). Presenting pathologies involving the external eye, cornea and conjunctiva accounted for 28.6% of the caseload.

CONCLUSION

This is the largest multicentre study assessing attendance patterns in HEECS in England. We have, for the first time, observed a "weekend effect" in relation to attendance to HEECS. Differences in health-seeking behaviour and lack of awareness of HEECS weekend services may be partly attributed to the differences observed. Our findings, along with the type of presentations, have the potential to guide commissioners with future planning of HEECS.

Characteristics of the ocular surface in neurotrophic keratitis induced by trigeminal nerve injury following neurosurgery

Purpose

To analyse and quantify ocular surface parameters in patients with unilateral neurotrophic keratitis (NK) induced by trigeminal nerve injury post-neurosurgery.

Methods

The study included 26 unilateral NK patients who had undergone neurosurgery, and 20 matched normal controls. Demographic and clinical characteristics of all participants were collected and analysed. Slit-lamp examination, Cochet–Bonnet aesthesiometry, Keratograph 5 M, and LipiView interferometer were performed on both eyes of 17 mild NK patients. For nine moderate/severe NK patients, sub-basal nerve density was measured by in vivo confocal microscopy.

Results

Of the 26 patients, nine had acoustic neuroma, nine had trigeminal neuralgia, and eight had neoplasms. Facial nerve paralysis was observed in one of the 17 mild NK eyes (5.9%) and seven of the nine moderate/severe NK eyes (77.8%). Compared to contralateral and normal control eyes, 26 NK eyes showed significantly reduced sensitivity in five corneal regions (P < 0.05). Corneal sensitivity in moderate/severe NK eyes was significantly lower than in mild NK eyes (P < 0.05). Moderate/severe NK eyes had poor visual acuity, and their sub-basal nerve density was lower than that of the controls. The onset of the moderate/severe NK was from 0.5 to 24 months (median [Q1, Q3], 1 [0.5, 2.5] months) after neurosurgery. For the mild NK eyes, the number of total blinks, the first non-invasive tear breakup time (NITBUT) and average NITBUT were significantly lower than contralateral and normal control eyes (P < 0.05), and the number of partial blinks and partial blinking rate were significantly higher than the other two control groups (P < 0.05).

Conclusions

Patients with NK induced by trigeminal nerve injury following neurosurgery had decreased corneal sensitivity to various degrees accompanied by increased partial blinks and shortened NITBUT. The severity of NK is related to the severity of the corneal sensory impairment. Facial nerve paralysis can worsen the clinical progression of NK.

Trial registration Chinese Clinical Trial Registry (ChiCTR2100044068, Date of Registration: March 9, 2021).

The impact of retinal fluid tolerance on the outcomes of neovascular age-related macular degeneration treated using aflibercept: A real-world study

This study investigated the impact of retinal fluid tolerance on retinal thickness and visual acuity in patients with neovascular age-related macular degeneration after 18 months of treatment using intravitreal aflibercept. This retrospective study was based on the medical records of 90 eyes presenting persistent or recurrent retinal fluid retention after 3 months of aflibercept loading injections. We defined the fluid tolerance ratio as the sum of fluid-tolerance duration divided by the total duration of retinal fluid observed throughout the follow-up period. Eyes were categorized into strict, intermediate, and relaxed group based on their fluid tolerance ratio (= 0, <30%, > = 30%, respectively). The mean total follow-up time was 556 days. The relaxed group required fewer injections than the strict group (4.92 vs 7.50 injections, P < 0.01) and presented a similar reduction in retinal thickness (-57.50 vs -71.65 μm, P = 0.83). Nonetheless, the two groups were similar in terms of final visual acuity (logarithm of the minimum angle of resolution 0.72 vs 0.70, P = 0.95) and visual gains (4.21 vs -1.12 letters, P = 0.56). These results indicate that in the setting of limited medical resources, a fluid-tolerant approach provides comparable gains in visual acuity. Reducing the number of injections may also improve adherence to therapy.

A study of the role and educational needs of ophthalmic specialist nurses

AIMS

To explore the current roles, responsibilities and educational needs of ophthalmic specialist nurses (OSNs) in the UK.

METHOD

A survey of 73 OSNs ranging from band 4 to band 8 was undertaken in May 2018.

FINDINGS

73% of OSNs undertake more than one active role, with 59% involved in nurse-led clinics; 63% felt formal learning resources were limited, with 63% reporting training opportunities and 21% reporting time as major barriers to further training. More than 38% emphasised hands-on clinic-based teaching had a greater impact on their educational needs. Some 64% were assessed on their skills annually and 59% felt confident with their skill set.

CONCLUSION

The Ophthalmic Common Clinical Competency Framework provides a curriculum and assessment tools for OSNs to use as a structure to maintain clinical skills and knowledge. Eye departments should use this as guidance to target learning needs and improve standards of care to meet the changing needs of society.

The Risks and Benefits of Myopia Control

PURPOSE

The prevalence of myopia is increasing around the world, stimulating interest in methods to slow its progression. The primary justification for slowing myopia progression is to reduce the risk of vision loss through sight-threatening ocular pathologic features in later life. The article analyzes whether the potential benefits of slowing myopia progression by 1 diopter (D) justify the potential risks associated with treatments.

METHODS

First, the known risks associated with various methods of myopia control are summarized, with emphasis on contact lens wear. Based on available data, the risk of visual impairment and predicted years of visual impairment are estimated for a range of incidence levels. Next, the increased risk of potentially sight-threatening conditions associated with different levels of myopia are reviewed. Finally, a model of the risk of visual impairment as a function of myopia level is developed, and the years of visual impairment associated with various levels of myopia and the years of visual impairment that could be prevented with achievable levels of myopia control are estimated.

RESULTS

Assuming an incidence of microbial keratitis between 1 and 25 per 10 000 patient-years and that 15% of cases result in vision loss leads to the conclusion that between 38 and 945 patients need to be exposed to 5 years of wear to produce 5 years of vision loss. Each additional 1 D of myopia is associated with a 58%, 20%, 21%, and 30% increase in the risk of myopic maculopathy, open-angle glaucoma, posterior subcapsular cataract, and retinal detachment, respectively. The predicted mean years of visual impairment ranges from 4.42 in a person with myopia of -3 D to 9.56 in a person with myopia of -8 D, and a 1-D reduction would lower these by 0.74 and 1.21 years, respectively.

CONCLUSIONS

The potential benefits of myopia control outweigh the risks: the number needed to treat to prevent 5 years of visual impairment is between 4.1 and 6.8, whereas fewer than 1 in 38 will experience a loss of vision as a result of myopia control.

Assessment of age‐related maculopathy using subjective vision tests

This paper reviews non-standard, clinical vision tests that may be used to detect the earliest visual loss in age-related maculopathy (ARM), before fundus changes are detected. We recommend a clinical test battery for all patients aged 60 years and older, comprising low luminance/low contrast (SKILL) VA or low contrast VA, desaturated D-15 colour vision assessment, flicker perimetry, glare recovery and dark adaptation if possible, together with conventional assessments of case history, ophthalmoscopy and high contrast visual acuity (VA) for the detection and diagnosis of ARM. Reading rate is also discussed as a potential indicator of early visual loss. For monitoring the progressive visual loss in age-related macular degeneration (AMD) and determining the requirements for optometric vision rehabilitation, we recommend more conventional clinical vision tests of distance and near visual acuity, reading rate, the effects of varying illumination and a functional central visual field assessment.

Cataract risk stratification and prioritisation protocol in the COVID-19 era

Background

The COVID-19 pandemic halted non-emergency surgery across Scotland. Measures to mitigate the risks of transmitting COVID-19 are creating significant challenges to restarting all surgical services safely. We describe the development of a risk stratification tool to prioritise patients for cataract surgery taking account both specific risk factors for poor outcome from COVID-19 infection as well as surgical ‘need’. In addition we report the demographics and comorbidities of patients on our waiting list.

Methods

A prospective case review of electronic records was performed. A risk stratification tool was developed based on review of available literature on systemic risk factors for poor outcome from COVID-19 infection as well as a surgical ‘need’ score. Scores derived from the tool were used to generate 6 risk profile groups to allow prioritised allocation of surgery.

Results

There were 744 patients awaiting cataract surgery of which 66 (8.9 %) patients were ‘shielding’. One hundred and thirty-two (19.5 %) patients had no systemic comorbidities, 218 (32.1 %) patients had 1 relevant systemic comorbidity and 316 (46.5 %) patients had 2 or more comorbidities. Five hundred and ninety patients (88.7 %) did not have significant ocular comorbidities. Using the risk stratification tool, 171 (23 %) patients were allocated in the highest 3 priority stages. Given an aging cohort with associated increase in number of systemic comorbidities, the majority of patients were in the lower priority stages 4 to 6.

Conclusions

COVID-19 has created an urgent challenge to deal safely with cataract surgery waiting lists. This has driven the need for a prompt and pragmatic change to the way we assess risks and benefits of a previously regarded as low-risk intervention. This is further complicated by the majority of patients awaiting cataract surgery being elderly with comorbidities and at higher risk of mortality related to COVID-19. We present a pragmatic method of risk stratifying patients on waiting lists, blending an evidence-based objective assessment of risk and patient need combined with an element of shared decision-making. This has facilitated safe and successful restarting of our cataract service.

Prevalence and determinants of uncorrected refractive error among a socially vulnerable older adult population living in Armenia

OBJECTIVE

This study estimated the prevalence of uncorrected refractive error (URE) and its determinants in a socially vulnerable older population living in Armenia.

STUDY DESIGN

The study design used in the stidy is a cross-sectional study.

METHODS

A total of 485 people responded to a survey on sociodemographic characteristics, spectacle use, and ophthalmic services' use. All participants underwent a comprehensive ophthalmic examination including assessment of presenting and best-corrected visual acuity, measuring intraocular pressure and dilated eye fundus examination. Patients who had presenting visual acuity (<6/12) but improved ≥ one line with/without available spectacles after refraction in the better eye were considered to have URE. Descriptive statistics described the sample and estimated the prevalence of the URE in the population. Logistic regression models were used to evaluate its determinants.

RESULTS

The mean age of participants was 74.5 (7.27) years, ranging from 51 to 94 years. Women constituted the majority of participants (86%). The prevalence of URE in the better eye was 26%. In bivariate analysis, those who were older and who had less than 10 years of education had higher odds of URE than younger and more educated respondents. In multivariable analysis, only education remained associated with URE (OR = 3.71; 95% CI: 1.10-12.5). The rate of normal vision (≥6/12) improved from 58.9% to 81.5%, whereas the rate of visual impairment (<6/12) decreased from 41.1% to 18.5% after best correction in the better eye.

CONCLUSION

The prevalence of URE was high in this study population. The findings warrant the need for eye screening and provision of affordable spectacle correction to the target population in Armenia.

Biotechnology and Biomaterial-Based Therapeutic Strategies for Age-Related Macular Degeneration. Part I: Biomaterials-Based Drug Delivery Devices

Age-related Macular Degeneration (AMD) is an up-to-date untreatable chronic neurodegenerative eye disease of multifactorial origin, and the main causes of blindness in over 65 years old people. It is characterized by a slow progression and the presence of a multitude of factors, highlighting those related to diet, genetic heritage and environmental conditions, present throughout each of the stages of the illness. Current therapeutic approaches, mainly consisting of intraocular drug delivery, are only used for symptoms relief and/or to decelerate the progression of the disease. Furthermore, they are overly simplistic and ignore the complexity of the disease and the enormous differences in the symptomatology between patients. Due to the wide impact of the AMD and the up-to-date absence of clinical solutions, the development of biomaterials-based approaches for a personalized and controlled delivery of therapeutic drugs and biomolecules represents the main challenge for the defeat of this neurodegenerative disease. Here we present a critical review of the available and under development AMD therapeutic approaches, from a biomaterials and biotechnological point of view. We highlight benefits and limitations and we forecast forthcoming alternatives based on novel biomaterials and biotechnology methods. In the first part we expose the physiological and clinical aspects of the disease, focusing on the multiple factors that give origin to the disorder and highlighting the contribution of these factors to the triggering of each step of the disease. Then we analyze available and under development biomaterials-based drug-delivery devices (DDD), taking into account the anatomical and functional characteristics of the healthy and ill retinal tissue.

Vision impairment and cognitive function among urban-dwelling malaysians aged 55 years and over from the Malaysian Elders Longitudinal Research (MELoR) study

INTRODUCTION

Published literature on vision impairment and cognitive function amongst older Malaysians remains scarce. This study investigates the association between vision impairment and cognitive function in an older Malaysian population.

METHODS

Subjects aged 55 years and above from the Malaysian Elders Longitudinal Research (MELoR) study with available information on vision and Montreal Cognitive Assessment (MoCA) scores were included. Data were obtained through a home-based interview and hospital-based health check by trained researchers. Visual acuity (VA) was assessed with logMAR score with vision impairment defined as VA 6/18 or worse in the better-seeing eye. Cognition was evaluated using the MoCA-Blind scoring procedure. Those with a MoCA-Blind score of <19/22 were considered to have cognitive impairment.

RESULTS

Data was available for 1144 participants, mean (SD) age = 68.57 (±7.23) years. Vision impairment was present in 143 (12.5 %) and 758 (66.3 %) had MoCA-Blind score of <19. Subjects with vision impairment were less likely to have a MoCA-Blind score of ≥19 (16.8 % vs 36.2 %, p < 0.001). Vision impairment was associated with poorer MoCA-Blind scores after adjustments for age, gender, and ethnicity (β = 2.064; 95 % CI, -1.282 to 3.320; P = 0.003). In those who had > 6 years of education attainment, vision impairment was associated with a significant reduction of cognitive function and remained so after adjustment for age and gender (β = 1.863; 95 % CI, 1.081-3.209; P = 0.025).

CONCLUSION

Our results suggest that vision impairment correlates with cognitive decline. Therefore, maintaining good vision is an important interventional strategy for preventing cognitive decline in older adults.

Pharmacological Advances in the Treatment of Age-related Macular Degeneration

Age-related macular degeneration is an acquired degenerative disease that is responsible for severe loss of vision in elderly people. There are two types: dry age-related macular degeneration and wet age-related macular degeneration. Its treatment has been improved and tries to be tailored in the future. The aim of this review is to summarize the pharmacological advances in the treatment of age-related macular degeneration. Regarding dry AMD, there is no effective treatment to reduce its progression. However, some molecules such as lampalizumab and eculizumab were under investigation, although they have shown low efficacy. Herein, in an attempt to prevent dry AMD progression, the most important studies suggested increasing the antioxidants intake and quitting the smoke habit. On the other hand, wet AMD has more developed treatment. Nowadays, the gold standard treatment is anti-VEGF injections. However, more effective molecules are currently under investigation. There are different molecules under research for dry AMD and wet AMD. This fact could help us treat our patients with more effective and lasting drugs but more clinical trials and safety studies are required in order to achieve an optimal treatment.

Accommodation and its role in myopia progression and control with soft contact lenses

PURPOSE

To examine the impact of contact lens optical design on accommodative behaviour of children and the correlation between myopia progression and the accommodative response of the eye while wearing a contact lens designed for myopia control.

METHODS

A post-hoc analysis was conducted on data from a previously published myopia control trial. A total of 109 subjects (aged 8 to 11 years, myopia: -0.75 to -4.00 D) wore either a Control (single-vision, n = 57) or a Test (with positive spherical aberration, +SA, n = 52) soft contact lens, binocularly for 1 year. Accommodative response was measured as the subject observed targets at -1.00 to -4.00 D vergence using the Grand Seiko WAM-5500 open-field autorefractor (www.grandseiko.com). Slope of accommodative response (SAR) as well as distance and near phoria and stimulus accommodative convergence/accommodation (AC/A) were compared between each group at baseline without study lenses and at 1-week and 1-year visits with study lenses. The SAR was also compared to changes in axial length (AL) and spherical equivalent cycloplegic auto refraction (SECAR).

RESULTS

At baseline, there was no significant difference in SAR between the two study groups (ΔSAR = -0.039, p = 0.84). At 1 week, mean SAR of the Test group was significantly less than for the Control group (ΔSAR = -0.203, p < 0.0001), an effect that persisted to 1 year (ΔSAR = -0.129, p < 0.0001). In the Test group, greater SAR was associated with less change in AL (regression coefficient: -0.59 mm, p < 0.0001) and SECAR (regression coefficient: 1.12 D, p = 0.006) at 1 year. In the Control group, associations between SAR and change in AL and SECAR were not statistically significant. Compared to the Control group, eyes of the Test group appeared to be more exophoric with study lenses, however, the difference between the two groups was only significant at 1 week for distance phoria and 1 year for near phoria.

CONCLUSION

The soft contact lens with +SA for controlling myopia progression resulted in an apparent decrease in mean accommodation. Within the Test group, reduced accommodative response correlated with greater myopia progression, suggesting some subjects in the Test group utilised the +SA for near viewing, inducing hyperopic defocus at the retina. Accordingly, the potential impact of a lens optics on accommodative function should be considered during design of myopia control lenses.

Evaluation of retinal function improvement in neovascular age-related macular degeneration after intravitreal aflibercept injections with the use of the assessment of retinal sensitivity: The use of the assessment of retinal sensitivity in anti-VEGF treatment - a STROBE-compliant observational study

This study compares 2 methods of macular function evaluation: the microperimetric examination (mean central retinal sensitivity and fixation stability) and the distance best-corrected visual acuity (BCVA) examination, which is the most frequently used method of assessing macular function in patients with newly diagnosed wet age-related macular degeneration (AMD) who have been treated with anti-vascular endothelial growth factor (VEGF) drug (aflibercept).Prospective analysis was conducted on 44 eyes of 44 patients treated with intravitreal injection of anti-VEGF (aflibercept) because of newly diagnosed neovascular AMD. According to the research protocol, all patients had a 6-month follow-up. The response to treatment was monitored functionallybyMP-1 microperimetry, fixation, and distance BCVA assessment after injection. Improvement of retinal sensitivity and BCVA was found under aflibercept treatment. There was statistically significant improvement in retinal sensitivity in the MP-1 study 3 and 6 months from the beginning of anti-VEGF therapy. Moreover, a significant improvement in retinal sensitivity between 3 and 6 months of observation was demonstrated. At the same time, up to 3 months from the beginning of treatment, BCVA improved significantly compared to the baseline value. In the 6th month of the study BCVA remained stable without further significant improvement.Microperimetric examination with medium sensitivity and fixation stability assessment is a very valuable test determining the retinal function. It is clear that examining the macular morphology itself in modern diagnostics is not enough to assess retinal function. Microperimetry technique is a valuable tool for functional long-term evaluation of retinal function (also for a period of more than 3 months).

Myopia Outcome Study of Atropine in Children (MOSAIC): an investigator-led, double-masked, placebo-controlled, randomised clinical trial protocol

Background: The Myopia Outcome Study of Atropine in Children (MOSAIC) aims to explore the efficacy, safety, acceptability and mechanisms of action of 0.01% unpreserved atropine for myopia control in a European population. Methods: MOSAIC is an investigator-led, double-masked, placebo-controlled, randomised clinical trial (RCT) investigating the efficacy, safety and mechanisms of action of 0.01% atropine for managing progression of myopia. During Phase 1 of the trial, 250 children aged 6-16 years with progressive myopia instil eye drops once nightly in both eyes from randomisation to month 24. From month 24 to 36  participants are re-randomised in Phase 2 of the trial, into continued 0.01% atropine, and washout, at 1:1 ratio for those participants initially randomised to the intervention arm (n=167), during which any potential rebound effects on cessation of treatment will be monitored. All participants initially assigned to the placebo (n=83) crossover to the intervention arm of the study for Phase 2, and from month 24 to 36, instil 0.01% atropine eye drops in both eyes once nightly. Further treatment and monitoring beyond 36 months is planned (Phase 3) and will be designed dependent on the outcomes of Phase 1. Results: The primary outcome measure is cycloplegic spherical equivalent refractive error progression at 24 months. Secondary outcome measures include axial length change as well as the rebound, safety and acceptability profile of 0.01% atropine. Additional analyses will include the mechanisms of action of 0.01% atropine for myopia control. Conclusions: The generalisability of results from previous clinical trials investigating atropine for myopia control is limited by the predominantly Asian ethnicity of previous study populations. MOSAIC is the first RCT to explore the efficacy, safety and mechanisms of action of unpreserved 0.01% atropine in a predominantly White population.

Barbosa RT, Valenti VE, Oliveira FR, Roque AL, Júnior HMFES, Garner DM, Raimundo RD, de Abreu LC. The effects of cataract surgery on autonomic heart rate control: a prospective cross-sectional and analytical study

OBJECTIVES

We aimed to evaluate the effects of cataract surgery on cardiac autonomic modulation.

METHODS

A cross-sectional and analytical study was conducted at the Hospital Maria Braido in the city of São Caetano do Sul, São Paulo, between 2015 and 2016. We investigated 19 patients of both sexes who were all over 50 years old; all patients had a diagnosis of senile or bilateral cataracts and were recommended to undergo implantation of the intraocular lens. Heart rate variability (HRV) was evaluated before, during and after cataract surgery.

RESULTS

There were no significant changes in the time and geometric domains of HRV before, during or after surgery. The high-frequency (HF) band in normalized units (nu) on the spectral analysis significantly increased (p=0.02, Cohen's d=0.9, large effect size). However, the low-frequency (LF) band in nu significantly decreased during surgery (p=0.02, Cohen's d=0.9, large effect size).

CONCLUSION

Throughout the intraocular lens implantation cataract surgery, there was an increase in parasympathetic modulation and a decrease in the sympathetic component of the heart rate (HR). We propose that this result is attributable to the supine position of the patients during surgery and the trigeminal reflex.

Myopia Outcome Study of Atropine in Children (MOSAIC): an investigator-led, double-masked, placebo-controlled, randomised clinical trial protocol

Background: The Myopia Outcome Study of Atropine in Children (MOSAIC) aims to explore the efficacy, safety, acceptability and mechanisms of action of 0.01% unpreserved atropine for myopia control in a European population.

Methods: MOSAIC is an investigator-led, double-masked, placebo-controlled, randomised clinical trial (RCT) investigating the efficacy, safety and mechanisms of action of 0.01% atropine for managing progression of myopia. During Phase 1 of the trial, 250 children aged 6-16 years with progressive myopia instil eye drops once nightly in both eyes from randomisation to month 24. No treatment is given during Phase 2 from month 24 to 36 (washout period) for those participants initially randomised to the intervention arm (n=167), during which any potential rebound effects on cessation of treatment will be monitored. All participants initially assigned to the placebo (n=83) crossover to the intervention arm of the study for Phase 2, and from month 24 to 36, instil 0.01% atropine eye drops in both eyes once nightly. Further treatment and monitoring beyond 36 months is planned (Phase 3) and will be designed dependent on the outcomes of Phase 1.

Results: The primary outcome measure is cycloplegic spherical equivalent refractive error progression at 24 months. Secondary outcome measures include axial length change as well as the rebound, safety and acceptability profile of 0.01% atropine. Additional analyses will include the mechanisms of action of 0.01% atropine for myopia control.

Conclusions: The generalisability of results from previous clinical trials investigating atropine for myopia control is limited by the predominantly Asian ethnicity of previous study populations. MOSAIC is the first RCT to explore the efficacy, safety and mechanisms of action of unpreserved 0.01% atropine in a predominantly White population.

Trial registration: ISRCTN: ISRCTN36732601 (04/10/2017), EudraCTdatabase 2016-003340-37 (03/07/2018).

[Cataract Surgery in Very Old Patients]

BACKGROUND

In recent years, there has been an increase in the number of very old patients requiring a cataract operation. However, there is little information on the intraoperative complications and safety in these patients. For various reasons, operations on patients from age 85 may be demanding: dense nuclear cataract, narrow pupils, low count of endothelial cells, loose zonula, and other ocular or systemic diseases. The aim of this retrospective study was to compare very old to younger cataract patients with respect to intraoperative complications and the maturity of the cataract.

PATIENTS AND METHODS

This was a retrospective study on 4065 cataract patients treated in our department with IOL implantation with the corneal small incision technique between January 2015 and January 2018. The patients were split by age (from 85 and under 85).

RESULTS

Of the 4065 cataract operations, 10.6% (431/4065) were performed on patients aged at least 85, 1.7% (69/4065) on patients aged at least 90 and 0.1% (4/4065) on patients of at least 95 years. There were statistically significant differences between the younger and older patients with respect to pupil dilatation (4.6 vs. 6.0%), use of the capsule tension ring (0.4 vs. 0%) and in capsule staining (5.5 vs. 7.0%). There were no intraoperative complications (e.g. anterior capsule laceration) in patients aged at least 85 and in 0.71% of patients aged under 85; loss of vitreous fluid was recorded in none of the patients in the older group and in 0.41% of patients in the younger group.

CONCLUSION

Our study confirms that advanced age alone is not a contraindication for a cataract operation and is not associated with a greater rate of intraoperative complications. Cataract operations on very old patients are generally successful, but should be undertaken early - particularly on multimorbid patients or those with dementia - in order to support the psychological status. The age of the patient is irrelevant.

Parental attitudes to myopia: a key agent of change for myopia control?

PURPOSE

With the increasing prevalence in myopia there is growing interest in active myopia prevention. This study aims to increase our understanding of parental attitudes to myopia development and control, as a means to inform future health planning and policy. It evaluates, for the first time, the attitude of parents to myopia and its associated risks, as well as assessing the exposure of Irish children to environmental factors that may influence their risk profile for myopia development.

METHODS

Parents of 8-13 year old children in eight participating schools completed a questionnaire designed to assess their knowledge of and attitudes towards myopia and its risk factors. A structured diary was also used to capture daily activities of children in relation to myopia risk factors.

RESULTS

Of 329 parents, just 46% considered that myopia presented a health risk to their children, while an identical number (46%) regarded it as an optical inconvenience. Myopia was also, but less frequently, considered an expense (31% of parents), a cosmetic inconvenience (14% of parents) and, by some, as a sign of intelligence (4% of parents) 76% of parents recognised the potential of digital technology to impact the eye, particularly as a cause of eyestrain and need for spectacles. Only 14% of parents expressed concern should their child be diagnosed with myopia. Compared to non myopic parents, myopic parents viewed myopia as more of an optical inconvenience (p < 0.001), an expense (p < 0.005) and a cosmetic inconvenience (p < 0.001). There was a trend for myopic parents to limit screen time use in their household more than non-myopic parents (p = 0.05). Parents who considered myopia a health risk sought to limit screen time more than parents who did not regard myopia as a health risk to their child (p = 0.01). Children spent significantly longer performing indoor proximal tasks (255 min) compared to time spent outdoors (180 min; p < 0.0001) daily. Older (p = 0.001), urban (p = 0.0005) myopic (=0.04) children spent significantly more time at digital screens compared to younger non-myopic children from a rural background.

CONCLUSION

Parental attitudes to myopia were typically nonchalant in relation to health risk. This is of particular concern given the impact parents have on children's behaviour and choices with respect to such risk factors, demonstrating an acute need for societal sensitisation to the public health importance of myopia.

Comprehensive sequencing of the myocilin gene in a selected cohort of severe primary open-angle glaucoma patients

Primary open-angle glaucoma (POAG) is the most common form of glaucoma, prevalent in approximately 1–2% of Caucasians in the UK over the age of 40. It is characterised by an open anterior chamber angle, raised intraocular pressure (IOP) and optic nerve damage leading to loss of sight. The myocilin gene (MYOC) is the most common glaucoma-causing gene, accounting for ~2% of British POAG cases. 358 patients were selected for next generation sequencing (NGS) with the following selection criteria: Caucasian ethnicity, intraocular pressure (IOP) 21–40 mm Hg, cup:disc ratio ≥0.6 and visual field mean deviation ≤−3. The entire MYOC gene (17,321 bp) was captured including the promoter, introns, UTRs and coding exons. We identify 12 exonic variants (one stop-gain, five missense and six synonymous variants), two promoter variants, 133 intronic variants, two 3′ UTR variants and 23 intergenic variants. Four known or predicted pathogenic exonic variants (p.R126W, p.K216K, p.Q368* and p.T419A) were identified across 11 patients, which accounts for 3.07% of this POAG cohort. This is the first time that the entire region of MYOC has been sequenced and variants reported for a cohort of POAG patients.

Influence of Parkinson's Disease on Judging Stair Step Height: Exploratory Study

This study investigated the effects of Parkinson's Disease (PD) on the perceptive judgment of stair step height using both exteroceptive visual and exproprioceptive judgments. We invited 14 individuals with PD and 14 neurologically healthy older adults (OA) to perform perceptual judgment tasks for first step stairway heights of 11 and 20 cm. Initially, participants performed first the exteroceptive visual judgment and then the exproprioceptive judgment in five randomized trials for each stair height. An analysis of variance for the exteroceptive visual judgment revealed no main effects or interaction between PD versus OA groups and height. However, the analysis of variance for exproprioceptive judgment revealed a significant interaction between group and height ( F_1,26 = 9.519; p = .005; Pη²= .268) such that both groups made more errors in exproprioceptive judgment at a height of 11 cm. The OA group made more errors in exproprioceptive judgment for the 20-cm step when compared with the PD group ( p = .016) but the PD group underestimated the step height. We conclude that PD influences exproprioceptive perception of step height and that steps with smaller (vs. larger) heights induce greater exproprioceptive error.

Global prevalence of visual impairment associated with myopic macular degeneration and temporal trends from 2000 through 2050: systematic review, meta-analysis and modelling

Purpose

We used systematic review and meta-analysis to identify and assimilate evidence quantifying blindness and visual impairment (VI) associated with myopic macular degeneration (MMD), then derived models to predict global patterns. The models were used to estimate the global prevalence of blindness and VI associated with MMD from 2000 to 2050.

Methods

The systematic review identified 17 papers with prevalence data for MMD VI fitting our inclusion criteria. Data from six papers with age-specific data were scaled to relative age-dependent risk and meta-analysed at VI and blindness levels. We analysed variance in all MMD VI and blindness data as a proportion of high myopia against variables from the place and year of data collection, with a model based on health expenditure providing the best correlation. We used this model to estimate the prevalence and number of people with MMD VI in each country in each decade.

Results

We included data from 17 studies comprising 137 514 participants. We estimated 10.0 million people had VI from MMD in 2015 (prevalence 0.13%, 95% CI 5.5 to 23.7 million, 0.07% to 0.34%), 3.3 million of whom were blind (0.04%, 1.8 to 7.8 million, 0.03% to 0.10%). We estimate that by 2050, without changing current interventions, VI from MMD will grow to 55.7 million people (0.57%, 29.0 to 119.7 million, 0.33% to 1.11%), 18.5 million of whom will be blind (0.19%, 9.6 to 39.7 million, 0.11% to 0.37%).

Conclusion

The burden of MMD blindness and VI will rise significantly without efforts to reduce the development and progression of myopia and improve the management of MMD.

Quality indicators in a community optometrist led cataract shared care scheme

PURPOSE

Cataract shared care schemes involving community optometrists show wide variation in practice. We report on defined key performance indicators (KPIs) which improve accountability between stakeholders.

METHODS

In this prospective study over nine months at a UK public hospital, we evaluated the outcomes of consecutive direct cataract referrals from community optometrists against two KPIs agreed under a service-level agreement between the Hospital Eye Service and community optometrists: (1) 85% of patients listed for cataract listing at first consultation; and (2) 90% postoperative feedback return rate on patients discharged to community optometrists. A detailed analysis on referral triage, surgical listing and postoperative form return rate is reported in this study.

RESULTS

A total of 733 direct cataract referrals were received using a designated referral form of which 86% were listed for cataract surgery. The predominant reason for not listing was a failure to reach the visual threshold set by the local clinical commissioning guidelines. Out of 569 cataract surgical episodes, 402 (71%) patients were discharged on the same day of surgery to community optometrist follow up. Completed postoperative feedback was returned from 374 patients (93%).

CONCLUSION

Direct cataract referrals from accredited community optometrists led to a majority of patients receiving a definitive clinical decision during first consultation. Postoperative community follow up reduced hospital visits and allowed for convenient consultation closer to home following uncomplicated cataract surgery. A service-level agreement with an accreditation scheme measured against KPIs enhances the accountability of stakeholders involved in the cataract shared care scheme.

The economic impact of sight loss and blindness in the UK adult population

BACKGROUND

To quantify the economic impact of sight loss and blindness in the United Kingdom (UK) population, including direct and indirect costs, and its burden on health.

METHODS

Prevalence data on sight loss and blindness by condition, Census demographic data, data on indirect costs, and healthcare cost databases were used. Blindness was defined as best corrected visual acuity (BCVA) of < 6/60, and sight loss as BCVA < 6/12 to 6/60, in the better-seeing eye.

RESULTS

Sight loss and blindness from age-related macular degeneration (AMD), cataract, diabetic retinopathy, glaucoma and under-corrected refractive error are estimated to affect 1.93 (1.58 to 2.31) million people in the UK. Direct health care system costs were £3.0 billion, with inpatient and day care costs comprising £735 million (24.6%) and outpatient costs comprising £771 million (25.8%). Indirect costs amounted to £5.65 (5.12 to 6.22) billion. The value of the loss of healthy life associated with sight loss and blindness was estimated to be £19.5 (15.9 to 23.3) billion or £7.2 (5.9 to 8.6) billion, depending on the set of disability weights used. For comparison with other published results using 2004 disability weights and the 2008 estimates, the total economic cost of sight loss and blindness was estimated to be £28.1 (24.0 to 32.5) billion in 2013. Using 2010 disability weights, the estimated economic cost of sight loss and blindness was estimated to be £15.8 (13.5 to 18.3) billion in 2013.

CONCLUSIONS

The large prevalence of sight loss and blindness in the UK population imposes significant costs on public funds, private expenditure, and health. Prevalence estimates relied on dated epidemiological studies and may not capture recent advances in treatment, highlighting the need for population-based studies that track the prevalence of sight-impairing eye conditions and treatment effects over time.

Self-reported vision impairment and incident prefrailty and frailty in English community-dwelling older adults: findings from a 4-year follow-up study

BACKGROUND

Little is known about vision impairment and frailty in older age. We investigated the relationship of poor vision and incident prefrailty and frailty.

METHODS

Cross-sectional and longitudinal analyses with 4-year follow-up of 2836 English community-dwellers aged ≥60 years. Vision impairment was defined as poor self-reported vision. A score of 0 out of the 5 Fried phenotype components was defined as non-frail, 1-2 prefrail and ≥3 as frail. Participants non-frail at baseline were followed-up for incident prefrailty and frailty. Participants prefrail at baseline were followed-up for incident frailty.

RESULTS

49% of participants (n=1396) were non-frail, 42% (n=1178) prefrail and 9% (n=262) frail. At follow-up, there were 367 new cases of prefrailty and frailty among those non-frail at baseline, and 133 new cases of frailty among those prefrail at baseline. In cross-sectional analysis, vision impairment was associated with frailty (age-adjustedandsex-adjusted OR 2.53, 95% CI 1.95 to 3.30). The association remained after further adjustment for wealth, education, cardiovascular disease, diabetes, falls, cognition and depression. In longitudinal analysis, compared with non-frail participants with no vision impairment, non-frail participants with vision impairment had twofold increased risks of prefrailty or frailty at follow-up (OR 2.07, 95% CI 1.32 to 3.24). The association remained after further adjustment. Prefrail participants with vision impairment did not have greater risks of becoming frail at follow-up.

CONCLUSION

Non-frail older adults who experience poor vision have increased risks of becoming prefrail and frail over 4 years. This is of public health importance as both vision impairment and frailty affect a large number of older adults.

Factors associated with vision-related quality of life among the adult population living in Nagorno Karabagh

OBJECTIVES

Visual impairment and blindness are major public health problems causing significant suffering, disability, loss of productivity, and diminishing quality of life for millions of people. This study explored the factors associated with the overall vision-related quality of life (VRQoL) and its different domains in the adult population of Nagorno Karabakh and assessed the independent contribution of specific eye diseases to VRQoL.

STUDY DESIGN

A cross-sectional study.

METHODS

We conducted interviewer-administered survey along with free eye screenings among adult residents of Hadrut and Martuni regions of Nagorno Karabakh (Artsakh) in 2014-2015. The study questionnaire included questions about sociodemographic characteristics, non-communicable diseases, use of eye care services, visual acuity, eye diseases, and VRQoL. National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) was used to assess VRQoL. In total, 531 adults participated in the study.

RESULTS

The mean age of participants was 60.1 years (standard deviation [SD] = 13.7), ranging from 18 to 90 years. The majority of participants were female (71.4%). The most frequently diagnosed eye disorder was cataract (33.8%). The prevalence of moderate and severe visual impairment was 7.0% and 0.8%, respectively. Almost 2.8% (15) of participants were blind. The mean global score of VFQ-25 in all study participants was 71.1 ± 19.28 (SD), whereas the mean global scores of VFQ-25 among not visually impaired, visually impaired, and blind participants were 74.0 ± 16.47 (SD), 51.7 ± 21.77 (SD), and 30.9 ± 20.2 (SD), respectively. In the adjusted linear regression model having moderate/severe visual impairment or blindness, age, socio-economic status, and having eye diseases such as glaucoma and cataract were significantly associated with VFQ-25 global score. The subscales of near vision, distance vision, peripheral vision, role difficulties, and mental health had significant associations with severe/moderate visual impairment in the adjusted analysis. After adjusting for visual impairment and demographic variables, participants with cataract and glaucoma were found to have statistically significant lower subscale scores than those without eye disease.

CONCLUSION

Our data suggest that visual impairment was associated with lower scores of VRQoL. The strength of that association correlated with the increase in the level of visual impairment (from moderate/severe impairment to blindness). VRQoL was also shown to be affected by age, socio-economic status, and having eye diseases such as glaucoma and cataract. Further actions of remediation of visual impairment in this population are warranted.

Unravelling the genetics of inherited retinal dystrophies: Past, present and future

The identification of the genes underlying monogenic diseases has been of interest to clinicians and scientists for many years. Using inherited retinal dystrophies as an example of monogenic disease we describe the history of molecular genetic techniques that have been pivotal in the discovery of disease causing genes. The methods that were developed in the 1970's and 80's are still in use today but have been refined and improved. These techniques enabled the concept of the Human Genome Project to be envisaged and ultimately realised. When the successful conclusion of the project was announced in 2003 many new tools and, as importantly, many collaborations had been developed that facilitated a rapid identification of disease genes. In the post-human genome project era advances in computing power and the clever use of the properties of DNA replication has allowed the development of next-generation sequencing technologies. These methods have revolutionised the identification of disease genes because for the first time there is no need to define the position of the gene in the genome. The use of next generation sequencing in a diagnostic setting has allowed many more patients with an inherited retinal dystrophy to obtain a molecular diagnosis for their disease. The identification of novel genes that have a role in the development or maintenance of retinal function is opening up avenues of research which will lead to the development of new pharmacological and gene therapy approaches. Neither of which can be used unless the defective gene and protein is known. The continued development of sequencing technologies also holds great promise for the advent of truly personalised medicine.

Soft Contact Lenses with Positive Spherical Aberration for Myopia Control

PURPOSE

To determine whether soft contact lenses with positive spherical aberration (+SA) can slow myopia progression.

METHODS

Eligible subjects (N = 127, primarily Asian) aged 8 to 11 years were randomized to wear either control (spherical design) or test (with +SA) soft daily disposable contact lenses for a minimum of 1 and up to 2 years (treatment phase). Subjects from the initial cohorts (N = 82) were then followed for an additional 1.5 years while wearing a marketed spherical daily disposable contact lens (withdrawal phase). Axial length and spherical equivalent cycloplegic autorefraction (SECAR) were measured at baseline and every 6 months in both phases.

RESULTS

During the first year of treatment, lens type (test vs. control) had a statistically significant impact on axial elongation (p = 0.0409). Eyes wearing test lenses increased in length by 0.11 (65.3%) and 0.14 (38.6%) mm less than eyes wearing control soft lenses at 6 and 12 months, respectively (p < 0.05 at both time points). The principal control of axial elongation occurred during the first 6 months. Spherical equivalent cycloplegic autorefraction change from baseline was significantly less in the test cohort than the control cohort by 0.21D (54.0%) at 6 months (p < 0.05) but not at 12 months (0.14D, p > 0.05). Lens type was not overall a significant factor affecting refractive error change (p = 0.0677). After ceasing treatment, neither the rate of axial elongation nor change in SECAR was significantly different between the initial two cohorts.

CONCLUSIONS

The soft contact lens with +SA slowed axial growth of the eye, although this did not translate into a sustained statistically significant effect on SECAR. The majority of the treatment effect occurred in the initial 6 months of wear. No evidence of rebound effect was observed after ceasing treatment.

The acceptability and visual impact of 0.01% atropine in a Caucasian population

BACKGROUND

Myopia is a condition of enormous public health concern, affecting up to 2.5 billion people worldwide. The most effective treatment to prevent myopia progression is atropine but at the cost of accommodative paresis and mydriasis, necessitating the use of bifocal glasses. Low-dose atropine (0.01%) has been found to be almost as effective with significantly reduced side effects. Since there are well-recognised differences in the effect of atropine between heavily pigmented Asian eyes and Caucasian eyes, this study aimed to determine the acceptability and tolerability of 0.01% atropine (by measuring visual performance and quality of life) as a treatment for myopia control in a Caucasian population exhibiting light irides.

METHODS

14 university students aged 18-27 were recruited to the study. Participants received one drop of 0.01% atropine daily into each eye over 5 days. A range of physiological, functional and quality of life measures were assessed at baseline, day 3 and day 5.

RESULTS

The effect of atropine was statistically significant for pupil size (p=0.04) and responsiveness (p<0.01). While amplitude of accommodation reduced, the change was not statistically significant. Visual acuity (distance and near) and reading speed were not adversely affected. While there was a slight increase in symptoms such as glare, overall there was no quality of life impact associated with the use of low-dose atropine.

CONCLUSIONS

Overall, 0.01% of atropine was generally well tolerated bilaterally and no serious adverse effects were observed. Therefore this dose appears to provide a viable therapeutic option for myopia control among Caucasian eyes.

Efficacy Comparison of 16 Interventions for Myopia Control in Children: A Network Meta-analysis

PURPOSE

To determine the effectiveness of different interventions to slow down the progression of myopia in children.

METHODS

We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov from inception to August 2014. We selected randomized controlled trials (RCTs) involving interventions for controlling the progression of myopia in children with a treatment duration of at least 1 year for analysis.

MAIN OUTCOME MEASURES

The primary outcomes were mean annual change in refraction (diopters/year) and mean annual change in axial length (millimeters/year).

RESULTS

Thirty RCTs (involving 5422 eyes) were identified. Network meta-analysis showed that in comparison with placebo or single vision spectacle lenses, high-dose atropine (refraction change: 0.68 [0.52-0.84]; axial length change: -0.21 [-0.28 to -0.16]), moderate-dose atropine (refraction change: 0.53 [0.28-0.77]; axial length change: -0.21 [-0.32 to -0.12]), and low-dose atropine (refraction change: 0.53 [0.21-0.85]; axial length change: -0.15 [-0.25 to -0.05]) markedly slowed myopia progression. Pirenzepine (refraction change: 0.29 [0.05-0.52]; axial length change: -0.09 [-0.17 to -0.01]), orthokeratology (axial length change: -0.15 [-0.22 to -0.08]), and peripheral defocus modifying contact lenses (axial length change: -0.11 [-0.20 to -0.03]) showed moderate effects. Progressive addition spectacle lenses (refraction change: 0.14 [0.02-0.26]; axial length change: -0.04 [-0.09 to -0.01]) showed slight effects.

CONCLUSIONS

This network analysis indicates that a range of interventions can significantly reduce myopia progression when compared with single vision spectacle lenses or placebo. In terms of refraction, atropine, pirenzepine, and progressive addition spectacle lenses were effective. In terms of axial length, atropine, orthokeratology, peripheral defocus modifying contact lenses, pirenzepine, and progressive addition spectacle lenses were effective. The most effective interventions were pharmacologic, that is, muscarinic antagonists such as atropine and pirenzepine. Certain specially designed contact lenses, including orthokeratology and peripheral defocus modifying contact lenses, had moderate effects, whereas specially designed spectacle lenses showed minimal effect.

Randomised, single-masked non-inferiority trial of femtosecond laser-assisted versus manual phacoemulsification cataract surgery for adults with visually significant cataract: the FACT trial protocol

INTRODUCTION

Cataract is one of the leading causes of low vision in the westernised world, and cataract surgery is one of the most commonly performed operations. Laser platforms for cataract surgery are now available, the anticipated advantages of which are broad and may include better visual outcomes through greater precision and reproducibility, and improved safety. FACT is a randomised single masked non-inferiority trial to establish whether laser-assisted cataract surgery is as good as or better than standard manual phacoemulsification.

METHODS AND ANALYSIS

808 patients aged 18 years and over with visually significant cataract will be randomised to manual phacoemulsification cataract surgery (standard care) or laser-assisted cataract surgery (intervention arm). Outcomes will be measured at 3 and 12 months after surgery. The primary clinical outcome is uncorrected distance visual acuity (UDVA, logMAR) at 3 months in the study eye recorded by an observer masked to the trial group. Secondary outcomes include UDVA at 12 months, corrected distance visual acuity at 3 and 12 months, complications, endothelial cell loss, patient-reported outcome measures and a health economic analysis conforming to National Institute for Health and Care Excellence standards.

ETHICS AND DISSEMINATION

Research Ethics Committee Approval was obtained on 6 February 2015, ref: 14/LO/1937. Current protocol: v2.0 (08/04/2015). Study findings will be published in peer-reviewed journals.

ISRCTN

77602616.

The clinical effectiveness and cost-effectiveness of second-eye cataract surgery: a systematic review and economic evaluation

BACKGROUND

Elective cataract surgery is the most commonly performed surgical procedure in the NHS. In bilateral cataracts, the eye with greatest vision impairment from cataract is operated on first. First-eye surgery can improve vision and quality of life. However, it is unclear whether or not cataract surgery on the second eye provides enough incremental benefit to be considered clinically effective and cost-effective.

OBJECTIVE

To conduct a systematic review of clinical effectiveness and analysis of cost-effectiveness of second-eye cataract surgery in England and Wales, based on an economic model informed by systematic reviews of cost-effectiveness and quality of life.

DATA SOURCES

Twelve electronic bibliographic databases, including MEDLINE, EMBASE, Web of Science, The Cochrane Library and the Centre for Reviews and Dissemination databases were searched from database inception to April 2013, with searches updated in July 2013. Reference lists of relevant publications were also checked and experts consulted.

REVIEW METHODS

Two reviewers independently screened references, extracted and checked data from the included studies and appraised their risk of bias. Based on the review of cost-effectiveness, a de novo economic model was developed to estimate the cost-effectiveness of second-eye surgery in bilateral cataract patients. The model is based on changes in quality of life following second-eye surgery and includes post-surgical complications.

RESULTS

Three randomised controlled trials (RCTs) of clinical effectiveness, three studies of cost-effectiveness and 10 studies of health-related quality of life (HRQoL) met the inclusion criteria for the systematic reviews and, where possible, were used to inform the economic analysis. Heterogeneity of studies precluded meta-analyses, and instead data were synthesised narratively. The RCTs assessed visual acuity, contrast sensitivity, stereopsis and several measures of HRQoL. Improvements in binocular visual acuity and contrast sensitivity were small and unlikely to be of clinical significance, but stereopsis was improved to a clinically meaningful extent following second-eye surgery. Studies did not provide evidence that second-eye surgery significantly affected HRQoL, apart from an improvement in the mental health component of HRQoL in one RCT. In the model, second-eye surgery generated 0.68 incremental quality-adjusted life-years with an incremental cost-effectiveness ratio of £1964. Model results were most sensitive to changes in the utility gain associated with second-eye surgery, but otherwise robust to changes in parameter values. The probability that second-eye surgery is cost-effective at willingness-to-pay thresholds of £10,000 and £20,000 is 100%.

LIMITATIONS

Clinical effectiveness studies were all conducted more than 9 years ago. Patients had good vision pre surgery which may not represent all patients eligible for second-eye surgery. For some vision-related patient-reported outcomes and HRQoL measures, thresholds for determining important clinical effects are either unclear or have not been determined.

CONCLUSIONS

Second-eye cataract surgery is generally cost-effective based on the best available data and under most assumptions. However, more up-to-date data are needed. A well-conducted RCT that reflects current populations and enables the estimation of health state utility values would be appropriate. Guidance is required on which vision-related, patient-reported outcomes are suitable for assessing effects of cataract surgery in the NHS and how these measures should be interpreted clinically.

STUDY REGISTRATION

This project is registered as PROSPERO CRD42013004211.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme.

Assessment of visual distortions in age-related macular degeneration: emergence of new approaches

AIMS

With the arrival of effective treatments for neovascular age-related macular degeneration (nvAMD) there is a need to find improved tests that would allow early detection. Ideally, these tests would allow monitoring of vision by patients themselves from home. The aim of this review is to discuss the available evidence for two recently developed vision tests designed for this purpose: the Preferential Hyperacuity Perimeter (PHP) test and the Radial Shape Discrimination (RSD) test.

METHODS

Articles that investigated detection of nvAMD were reviewed. The methodology of the clinical evidence, where available, was judged for bias and applicability of the results to the general population using the QUADAS-2 quality assessment tool.

RESULTS

The PHP test has proved to be good at detecting nvAMD but many studies assessed in this review were biased in the selection of patients, restricting the results to only those patients who can use the test and produce reliable results. On the other hand the RSD test is a simple test, well accepted by elderly patients with AMD. However, clinical studies to determine its value in the detection of early signs of nvAMD are still required.

CONCLUSIONS

To date, more studies have investigated the utility of the PHP test compared with the RSD test for detection of nvAMD. Both tests show promise but further evidence is needed to determine the real generalisability of the PHP test and the sensitivity of the RSD test.

Cataract after repeated daily in vivo exposure to ultraviolet radiation

Epidemiological data indicate a correlation between lifelong exposure to ultraviolet radiation and cortical cataract. However, there is no quantitative experimental data on the effect of daily repeated in vivo exposures of the eye to UVR. Therefore, this experiment was designed to verify whether the dose additivity for UVR exposures holds through periods of time up to 30 d. Eighty rats were conditioned to a rat restrainer 5 d prior to exposure. All animals were divided into four exposure period groups of 1, 3, 10, and 30 d of exposure to UVR. Each exposure period group of 20 animals was randomly divided into five cumulated UVR dose subgroups. Eighteen-wk-old non-anesthetized albino Sprague-Dawley rats were exposed daily to UVR-300 nm for 15 min. One week after the last exposure, animals were sacrificed. The lenses were extracted for macroscopic imaging of dark-field anatomy, and degree of cataract was quantified by measurement of the intensity of forward lens light scattering. Maximum tolerable dose (MTD(2.3:16)), a statistically defined standard for sensitivity for the threshold for UVR cataract, was estimated for each exposure period. Exposed lenses developed cataract with varying appearance on the anterior surface. Single low doses of UVR accumulated to cause cataract during periods up to 30 d. MTD(2.3:16) for 1, 3, 10, and 30 d of repeated exposures was estimated to 4.70, 4.74, 4.80, and 6.00 kJ m(-2), respectively. In conclusion, the lens sensitivity to UVR-B for 18-wk-old Sprague-Dawley rats decreases with the increasing number of days being exposed.

Heuristics in primary care for recognition of unreported vision loss in older people: a technology development study

AIM

To evaluate heuristics (rules of thumb) for recognition of undetected vision loss in older patients in primary care.

BACKGROUND

Vision loss is associated with ageing, and its prevalence is increasing. Visual impairment has a broad impact on health, functioning and well-being. Unrecognised vision loss remains common, and screening interventions have yet to reduce its prevalence. An alternative approach is to enhance practitioners' skills in recognising undetected vision loss, by having a more detailed picture of those who are likely not to act on vision changes, report symptoms or have eye tests. This paper describes a qualitative technology development study to evaluate heuristics for recognition of undetected vision loss in older patients in primary care.

METHOD

Using a previous modelling study, two heuristics in the form of mnemonics were developed to aid pattern recognition and allow general practitioners to identify potential cases of unreported vision loss. These heuristics were then analysed with experts. Findings It was concluded that their implementation in modern general practice was unsuitable and an alternative solution should be sort.

Assessment of the Visual Status of Older Adults on an Orthopedic Unit

PURPOSE. To examine the visual status of a cohort of older adults on an orthopedic unit to determine their level of available vision to complete everyday activities in the hospital setting.

METHOD. A convenience sample of 50 people was recruited. A visual history was obtained, and participants’ glasses were inspected. Distance acuity, reading acuity, and contrast sensitivity were assessed using standardized screening charts.

RESULTS. Of participants, 26% did not have their glasses with them until prompted, and 85% had glasses in poor condition. When tested wearing their habitual correction, 6% had low vision, 2% were blind, 41% had reading acuities worse than 20/25, and 28% had contrast sensitivity deficits.

CONCLUSION. Visual impairment is prevalent in older adults, yet visual function is not routinely screened in hospitals. Occupational therapists should routinely inquire about patients’ visual status, inspect their glasses, and encourage regular eye examinations. Failure to address vision could lead to inaccurate evaluation results.

Population-based assessment of sensitivity and specificity of a pinhole for detection of significant refractive errors in the community

BACKGROUND

Measurements of refractive errors through subjective or automated refraction are not always possible in rapid assessment studies and community vision screening programs; however, measurements of vision with habitual correction and with a pinhole can easily be made. Although improvements in vision with a pinhole are assumed to mean that a refractive error is present, no studies have investigated the magnitude of improvement in vision with pinhole that is predictive of refractive error. The aim was to measure the sensitivity and specificity of 'vision improvement with pinhole' in predicting the presence of refractive error in a community setting.

METHODS

Vision and vision with pinhole were measured using a logMAR chart for 488 of 582 individuals aged 15 to 50 years. Refractive errors were measured using non-cycloplegic autorefraction and subjective refraction. The presence of refractive error was defined using spherical equivalent refraction (SER) at two levels: SER greater than ± 0.50 D sphere (DS) and SER greater than ±1.00 DS. Three definitions for significant improvement in vision with a pinhole were used: 1. Presenting vision less than 6/12 and improving to 6/12 or better, 2. Improvement in vision of more than one logMAR line and 3. Improvement in vision of more than two logMAR lines.

RESULTS

For refractive error defined as spherical equivalent refraction greater than ± 0.50 DS, the sensitivities and specificities for the pinhole test predicting the presence of refractive error were 83.9 per cent (95% CI: 74.5 to 90.9) and 98.8 per cent (95% CI: 97.1 to 99.6), respectively for definition 1. Definition 2 had a sensitivity 89.7 per cent (95% CI: 81.3 to 95.2) and specificity 88.0 per cent (95% CI: 4.4 to 91.0). Definition 3 had a sensitivity of 75.9 per cent (95% CI: 65.5 to 84.4) and specificity of 97.8 per cent (95% CI: 95.8 to 99.0). Similar results were found with spherical equivalent refraction greater than ±1.00 DS, when tested against the three pinhole-based definitions.

CONCLUSION

Refractive error definitions based on improvement in vision with the pinhole shows good sensitivity and specificity at predicting the presence of significant refractive errors. These definitions can be used in rapid assessment surveys and community-based vision screenings.

The relationship between age and the intraoperative complication rate during phacoemulsification surgery

AIM

The aim of this study was to determine if aging is a factor that increases the intraoperative complication rate during phacoemulsification surgery.

MATERIALS AND METHODS

Patients who underwent phacoemulsification surgery were divided into three age groups according to World Health Organization classification, as follows: ≤ 59, 60-74, and ≥ 75 years. The intraoperative complications which occurred during the operation were recorded. Binary logistics regression analysis, Pearson’s correlation analysis, and Duncan’s (multiple range) test were used for statistical analysis.

RESULTS

In total, 789 patients who underwent phacoemulsification surgery at Nigde State Hospital, Ophthalmology Clinic between 01 July 2010 and 31 October 2012 were retrospectively reviewed, and intraoperative complications that occurred during surgery were recorded. Mean age of the patients was 68.98 years (range 38–93 years). In all, 132 (16.7 %) patients were aged ≤ 59 years, 406 (51.5 %) were aged 60 - 74 years, and 251 (31.8 %) were aged ≥ 75 years. The complication rates were 3.78 % in the ≤ 59-year-old age group, 5.17 % in the 60- to 74-year-old age group, and 5.30 % in the ≥ 75-year-old age group. Age did not have a significant effect on intraoperative complication rates during phacoemulsification surgery, according to binary logistic regression analysis (P = 0.58) and Pearson’s correlation analysis (P = 0.076). The incidence and risk of intraoperative complications in the age groups did not differ statistically (Duncan’s test, P = 0.18).

CONCLUSION

Age has no effect on the rate of intraoperative complications during phacoemulsification surgery.

An epidemiological study of neovascular age-related macular degeneration in Germany

OBJECTIVE

Neovascular or wet age-related macular degeneration (AMD) is one of the leading causes of blindness in industrialized countries; however, there is a lack of recent epidemiological data from Germany. The aim of this study was to collect epidemiological data from patients in Germany with suspected neovascular AMD and evaluate the diagnostic procedures performed and treatments used at clinics.

METHODS

This was a Germany-based, multicentre, retrospective review of data from patients with suspected neovascular AMD visiting ophthalmology clinics over an 18 month period in 2008-10. Clinical characteristics, functional symptoms and examination results were recorded. In addition, ophthalmologists completed a questionnaire on neovascular AMD diagnosis and treatment.

RESULTS

Ten sites collected data from 2498 patients (64.0% female) with a mean decimal visual acuity of 0.4 ± 0.3 at the time of diagnosis of neovascular AMD. The mean age at the time of diagnosis was 76.9 ± 8.9 years for patients with the right eye affected and 77.0 ± 8.3 years for patients with the left eye affected. The most frequent pathological findings detected by routine ophthalmic examination were old lesions (31.2%), intra/subretinal fluid (18.1%), new lesions (13.0%), and intra/subretinal haemorrhage (11.4%). A confirmed diagnosis of neovascular AMD was most frequently based on fundoscopy (67.3%), fluorescein angiography (39.6%), and biomicroscopy (35.7%) tests but rarely on optical coherence tomography (8.9%). The most frequently documented comorbidity with neovascular AMD was hypertension and other cardiovascular diseases (57.5%). Seven ophthalmologists completed the questionnaire with the majority of ophthalmologists agreeing that regular ophthalmic examination can prevent the development of late-stage neovascular AMD.

CONCLUSION

Neovascular AMD is a frequent diagnosis in German ophthalmology clinics. As visual acuity is already poor in most patients with suspected neovascular AMD, regular preventive ophthalmologic examinations should be considered in high risk patients.

STUDY LIMITATIONS

Limitations of the study include the lack of a comparator cohort, which limited the amount of analyses that could be performed. Additionally, a study eye was not defined and information was collected separately for each affected eye and therefore analysed separately. Furthermore, a small number of ophthalmologists completed the questionnaire, limiting the objectivity.

Health risk appraisal in older people 6: factors associated with self-reported poor vision and uptake of eye tests in older people

BACKGROUND

Although free eye testing is available in the UK from a nation-wide network of optometrists, there is evidence of unrecognised, tractable vision loss amongst older people. A recent review identified this unmet need as a priority for further investigation, highlighting the need to understand public perceptions of eye services and barriers to service access and utilisation. This paper aims to identify risk factors for (1) having poor vision and (2) not having had an eyesight check among community-dwelling older people without an established ophthalmological diagnosis.

METHODS

Secondary analysis of self-reported data from the ProAge trial. 1792 people without a known ophthalmological diagnosis were recruited from three group practices in London.

RESULTS

Almost two in ten people in this population of older individuals without known ophthalmological diagnoses had self-reported vision loss, and more than a third of them had not had an eye test in the previous twelve months. In this sample, those with limited education, depressed mood, need for help with instrumental and basic activities of daily living (IADLs and BADLs), and subjective memory complaints were at increased risk of fair or poor self-reported vision. Individuals with basic education only were at increased risk for not having had an eye test in the previous 12 months (OR 1.52, 95% CI 1.17-1.98 p=0.002), as were those with no, or only one chronic condition (OR 1.850, 95% CI 1.382-2.477, p<0.001).

CONCLUSIONS

Self-reported poor vision in older people without ophthalmological diagnoses is associated with other functional losses, with no or only one chronic condition, and with depression. This pattern of disorders may be the basis for case finding in general practice. Low educational attainment is an independent determinant of not having had eye tests, as well as a factor associated with undiagnosed vision loss. There are other factors, not identified in this study, which determine uptake of eye testing in those with self-reported vision loss. Further exploration is needed to identify these factors and lead towards effective case finding.

Results of cataract surgery in the very elderly population

AIM

The aim of our study was to retrospectively evaluate the effectiveness and safety of cataract surgery and intraocular lens implantation (IOL) for patients aged 90 years or older, whom we define as "very elderly."

METHODS

The study involved a total number of 122 patients (122 eyes) with senile cataracts. The mean age of patients was 91.2 ± 2.3 years (range 90-100 years old). Phacoemulsification (phaco) was done on 113 of 122 eyes, and 9 of 122 eyes had extracapsular cataract extraction (ECCE). Postoperative visual acuity and intraocular pressure (IOP) were analyzed on the first postoperative day, 3 months after surgery, and 6 months after surgery.

RESULTS

Best corrected visual acuity (BCVA) improved in 100 of 122 eyes (82.0%). BCVA remained the same in 20 of 122 eyes (16.4%) and decreased in 2 of 122 eyes (1.6%), mainly because of coexisting age-related macular degeneration (AMD). The BCVA 3 months after surgery was ≥0.8 in 23 of 122 eyes (18.9%), between 0.5 and 0.7 in 28 of 122 eyes (22.3%), and between 0.2 and 0.4 in 33 of 122 eyes (27.1%). We found significant implications of cataract surgery on decreasing IOP in the studied group of patients suffering from glaucoma compared to the patients without glaucoma.

CONCLUSION

Advanced age is not a contraindication for cataract surgery. The results of the study showed that when systemic conditions are stable, both phaco and ECCE with IOL for very elderly patients are effective and safe.

Spectacle coverage and spectacles use among elderly population in residential care in the south Indian state of Andhra Pradesh

Background. There is limited research conducted on uncorrected refractive errors, presbyopia, and spectacles use among the elderly population in residential care in developing countries such as India. We conducted a cross-sectional study among elderly in residential care to assess the spectacle coverage and spectacles usage in the south Indian state of Andhra Pradesh. Methods. All 524 residents in the 26 “homes for aged” institutions in the district were enumerated. Eye examination was performed that included visual acuity (VA) assessment for distant and near vision. A questionnaire was used to collect information on spectacles use. Results. 494/524 individuals were examined, 78% were women, and 72% had no education. The mean age of participants was 70 years. The spectacle coverage for refractive errors was 35.1% and 23.9% for presbyopia. The prevalence of current use and past use of spectacles was 38.5% (95% CI: 34.2–42.8; n = 190) and 17.2% (95% CI: 13.9–42.8), respectively. Conclusions. There is low spectacle coverage for both refractive errors and presbyopia among elderly individuals in residential care in the south Indian state of Andhra Pradesh. Appropriate service delivery systems should be developed to reach out this vulnerable group of seniors on a priority basis.