Trends in blind registration in the adult population of the Republic of Ireland 1996-2003

Sight impairment registration in Trinidad: trend in causes and population coverage in comparison to the National Eye Survey of Trinidad and Tobago

BACKGROUND

Little was known about the population coverage and causes of sight impairment (SI) registration within the Caribbean, or the extent to which register studies offer insights into population eye health.

METHODS

We compared causes of SI registration in the Trinidad and Tobago Blind Welfare Association (TTBWA) register with findings from the 2014 National Eye Survey of Trinidad and Tobago (NESTT), and estimated registration coverage. Cross-sectional validation studies of registered clients included interviews, visual function and cause ascertainment in July 2013, and interviews and visual function in July 2016.

RESULTS

The TTBWA register included 863 people (all ages, 48.1%(n = 415) male) registered between 1951 and 2015. The NESTT identified 1.1%(75/7158) people aged ≥5years eligible for partial or severe SI registration, of whom 49.3%(n = 37) were male. Registration coverage was approximately 7% of the eligible population of Trinidad. Nevertheless, there was close agreement in the causes of SI comparing the register and population-representative survey. Glaucoma was the leading cause in both the register (26.1%,n = 225) and population-based survey (26.1%, 18/69 adults), followed by cataract and diabetic retinopathy. In the validation studies combined, 62.6%(93/151) clients had severe SI, 28.5%(43/151) had partial SI and 9.9%(15/151) did not meet SI eligibility criteria. SI was potentially avoidable in at least 58%(n = 36/62) adults and 50%(n = 7/14) children.

CONCLUSION

We report very low register coverage of the SI population, but close agreement in causes of SI to a contemporaneous national population-based eye survey, half of which resulted from preventable or treatable eye disease.

Literature review and proposal of best practice for ophthalmologists: monitoring of patients following intravitreal brolucizumab therapy

Brolucizumab is a novel humanised, single-chain, variable fragment inhibitor of Vascular Endothelial Growth Factor-A for the treatment of neurovascular age-related macular degeneration. Brolucizumab gained US Food and Drug Administration and European Medicines Agency approval following the Phase III HAWK (NCT02307682) and HARRIER (NCT02434328) trials which compared brolucizumab with aflibercept, presenting a tolerable safety and favourable efficacy profile. The mean change (least squares [LS] mean ± standard error) in best-corrected visual acuity letters from baseline to week 96 in the HAWK trial was 5.9 ± 0.78 for brolucizumab (6 mg) versus 5.3 ± 0.78 for aflibercept, and in the HARRIER trial, 6.1 ± 0.73 (6 mg) for brolucizumab (6 mg) and 6.6 ± 0.73 for aflibercept. Within both trials, greater reductions were noted in the central subfield thickness from baseline to week 96 in the brolucizumab (6 mg) groups versus the aflibercept group. Subsequent post-marketing reports detailed intraocular inflammation (IOI) after brolucizumab treatment and in response an independent safety review committee conducted a post hoc data review. While comparable, the rate of brolucizumab-associated IOI was higher in the post hoc analysis than the trials (4.6% and 4.4%, respectively). Findings from trials and real-world data indicate there may be pre-defining risk factors that predispose patients to IOI following brolucizumab treatment. With a thorough understanding of IOI classification and best practice management, ophthalmologists can use brolucizumab confidently and, should a case arise, they should act quickly to prevent vision loss. Herein, we provide information and guidance to support clinical decision-making related to brolucizumab use.

Using electronic medical record data to establish and monitor the distribution of refractive errors. JOURNAL OF OPTOMETRY 2022;15 Suppl 1:S32-S42. [PMID: 36220741 PMCID: PMC9732486 DOI: 10.1016/j.optom.2022.09.001]

OBJECTIVE

To establish the baseline distribution of refractive errors and associated factors amongst a population that attended primary care optometry clinics.

DESIGN

Retrospective cross sectional cohort study of electronic medical records (EMR).

METHODS

Electronic medical record data was extracted from forty optometry clinics, representing a mix of urban and rural areas in Ireland. The analysis was confined to demographic and clinical data gathered over a sixty-month period between 2015 and 2019. Distribution rates were calculated using the absolute and relative frequencies of refractive error in the dataset, stratified for age and gender using the following definitions: high myopia ≤ -6.00 D, myopia ≤ -0.50 D, hyperopia ≥ +0.50 D, astigmatism ≤ -0.75 DC and anisometropia ≥ 1.00 D. Visual acuity data was used to explore vision impairment rates in the population. Further analysis was carried out on a gender and age-adjusted subset of the EMR data, to match the proportion of patients in each age grouping to the population distribution in the most recent (2016) Irish census.

RESULTS

153,598 clinic records were eligible for analysis. Refractive errors ranged from -26.00 to +18.50 D. Myopia was present in 32.7%, of which high myopia represented 2.4%, hyperopia in 40.1%, astigmatism in 38.3% and anisometropia in 13.4% of participants. The clinic distribution of hyperopia, astigmatism and anisometropia peaked in older age groups, whilst the myopia burden was highest amongst people in their twenties. A higher proportion of females were myopic, whilst a higher proportion of males were hyperopic and astigmatic. Vision impairment (LogMAR > 0.3) was present in 2.4% of participants. In the gender and age- adjusted distribution model, myopia was the most common refractive state, affecting 38.8% of patients.

CONCLUSION

Although EMR data is not representative of the population as a whole, it is likely to provide a reasonable representation of the distribution of clinically significant (symptomatic) refractive errors. In the absence of any ongoing traditional epidemiological studies of refractive error in Ireland, this study establishes, for the first time, the distribution of refractive errors observed in clinical practice settings. This will serve as a baseline for future temporal trend analysis of the changing pattern of the distribution of refractive error in EMR data. This methodology could be deployed as a useful epidemiological resource in similar settings where primary eyecare coverage for the management of refractive error is well established.

Audit of outcomes following attendance at the City West drive-through IOP glaucoma clinic during the COVID-19 pandemic

BACKGROUND

Glaucoma is the leading cause of irreversible blindness globally. During the COVID-19 pandemic, an enforced reduction in capacity resulted in the deferral of routine outpatient appointments for glaucoma patients.

AIM

This study analyses patient outcomes following the establishment of a drive-through intra-ocular pressure (IOP) clinic during the COVID-19 pandemic to alleviate increased pressure on the tertiary glaucoma services at Royal Victoria Eye and Ear Hospital (RVEEH) and Mater Misericordiae University Hospital (MMUH) between August 2020 and June 2021.

METHODS

A 1-lane driveway system was established in a marquee on the grounds of City West hotel. IOPs were measured in patients' cars using a hand held iCare100 tonometer. Results were reviewed by a consultant ophthalmologist. At hospital follow-up clinic visits, IOP was measured using the Goldmann applanation tonometer (GAT).

RESULTS

Three hundred one patients of a total of 672 who attended the drive-through clinic have subsequently attended a designated hospital follow-up appointment. In this cohort, the mean drive-through iCare IOP of 19.4 mmHg ± 6.0 was significantly higher (< 0.005) than the mean GAT IOP at the pre-drive through clinic visit (16.3 mmHg ± 3.7) and the post drive-through hospital follow-up visit (17.2 mmHg ± 4.1). Two hundred twenty-six (75%) patients did not need any treatment change, 53 (18%) required eye drop medication changes, 10 (3%) underwent a laser procedure, 4(1%) required surgical intervention, and 8 (3%) were discharged. When patient outcomes were analysed according to IOP grade assigned at the drive-through clinic, those with an iCare IOP < 21 were significantly less likely to require a treatment change. The cohort with iCare IOP ≥ 30 were significantly more likely to have a laser or surgical intervention.

CONCLUSION

The implementation of a drive-through IOP clinic was a safe and effective way to monitor glaucoma patients during COVID-19, and identify those at high risk of poor IOP control or requiring a change in treatment.

Blindness and visual impairment in Central Europe

Purpose

To assess the prevalence and causes of visual impairment and blindness in a Central European country. The findings may have implications for the planning of further research and development of therapies in order to prevent blindness.

Setting

Department of Ophthalmology, Medical University of Graz, Austria.

Design

Retrospective, epidemiological study.

Methods

The database of the Main Confederation of Austrian Social Insurances was searched for patients with visual impairment, legal blindness or deaf-blindness. This database gathers data from patients of all insurance providers in the country who receive care due to visual impairment and blindness. To determine the prevalence of these conditions, the number of all entries recorded in February 2019 was evaluated. Additionally, all new entries between (January 1^st,) 2017, and (December 31^st,) 2018, were analysed for distinct characteristics, such as sex, the cause of blindness/visual impairment, and age. Since health care allowances can provide a considerable source of income (459.90€-936.90€ per month), good coverage of practically all patients who are blind and visually impaired in the country can be assumed.

Results

On February 2^nd, 2019, 17,730 patients with visual impairments, blindness or deaf-blindness were registered in Austria, resulting in a prevalence of these diagnoses of 0.2% in the country. During the observational period from 2017 to 2018, 4040 persons met the inclusion criteria. Of these, 2877 were female (65.3%), and 1527 were male (34.7%). The mean age was 75.7 ± 18.0 years (median 82). Most patients (n = 3675, 83.4%) were of retirement age, while 729 (16.6%) were working-age adults or minors. In total, an incidence of 25.0 (95% confidence limit (CL) 24.3–25.8) per 100,000 person-years was observed from 2017 to 2018. A higher incidence was observed for females (32.2, 95% CL 31.0–33.3) than for males (17.7, 95% CL 16.8–18.5). Incidences where higher for males in lower age groups (e.g. 10–14 years: rate ratio RR = 2.7, 95% CL 1.1–6.8), and higher for females in higher age groups (e.g. 70–74 years: RR = 0.6, 95% CL 0.5–0.8). In total, the most frequent diagnoses were macular degeneration (1075 persons, 24.4%), other retinal disorders (493 persons, 11.2%) and inherited retinal and choroidal diseases (IRDs) (186 persons, 4.2%). Persons with IRDs were significantly younger compared to persons with macular degeneration or retinal disorders (IRDs: median 57, range 2–96 vs 83, 5–98 and 82, 1–98 years, p<0.001). For persons of retirement age, macular degeneration, other retinal disorders and glaucoma were the three most frequent diagnoses. In contrast, among working-aged adults and children, IRDs were the leading cause of visual impairment and blindness (103 persons, 14.1%).

Conclusion

These data show that IRDs are the leading cause of blindness and visual impairment in working-aged persons and children in Austria. Thus, these findings suggest to draw attention to enhance further research in the fields of emerging therapies for IRDs.

Diabetic Retinopathy Screening and Registration in Europe-Narrative Review

Diabetic retinopathy (DR) is a leading cause of preventable vision impairment and blindness in the European Region. Despite the fact that almost all European countries have some kind of prophylactic eye examination for people with diabetes, the examinations are not properly arranged and are not organized according to the principles of screening in medicine. In 2021, the current COVID-19 pandemic moved telemedicine to the forefront healthcare services. Due to that, a lot more patients could benefit from comfortable and faster access to ophthalmology specialist care. This study aimed to conduct a narrative literature review on current DR screening programs and registries in the European Union for the last 20 years. With the implementation of telemedicine in daily medical practice, performing screening programs became much more attainable. Remote assessment of retinal pictures simultaneously saves countries time, money, and other resources.

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.

The prevalence of sight impairment registration post-stroke

Many stroke survivors are eligible for sight impairment (SI) registration from a chronic visual impairment (VI). The literature and clinical experience show that some individuals who meet the criteria for registration either decline or are not offered registration. The aim of this Orthoptic stroke service review is to determine the reason for declining and whether the individuals feel supported without registration and to recommend service changes to improve the certification process. A service evaluation of stroke survivors who had declined SI registration was undertaken. All those with a diagnosis of stroke, a full Orthoptic assessment, a period of monitoring and were discharged between September 2017 and August 2019 were identified. . Fifty-four stroke survivors were eligible to be registered SI at their last appointment; 31 (57%) were not offered registration for reasons including end of life care. Of the remaining 23s, 14 proceeded with SI registration and nine declined. Four who declined were excluded (44%), as two were registered at a subsequent ophthalmology appointment, two were inappropriate to contact. A telephone interview was undertaken with the remaining five individuals. Of the five stroke survivors that were contacted, three (60%) recalled declining SI registration at their last appointment. All felt they were given enough information to aid their decision. Reasons given for declining registration included not accepting the VI, hoping for recovery and having enough support. The individuals felt they were still able to access services and were happy to remain unregistered. The remaining two stroke survivors could not recall being offered SI registration and subsequently requested to be registered following the telephone call. Of those individuals who initially declined registration, two (40%) decided to proceed with registration following the telephone interview. Although numbers are small it is worth considering a post discharge telephone consultation to stroke survivors who decline registration.

Development of an intervention to facilitate implementation and uptake of diabetic retinopathy screening

BACKGROUND

'Implementation interventions' refer to methods used to enhance the adoption and implementation of clinical interventions such as diabetic retinopathy screening (DRS). DRS is effective, yet uptake is often suboptimal. Despite most routine management taking place in primary care and the central role of health care professionals (HCP) in referring to DRS, few interventions have been developed for primary care. We aimed to develop a multifaceted intervention targeting both professionals and patients to improve DRS uptake as an example of a systematic development process combining theory, stakeholder involvement, and evidence.

METHODS

First, we identified target behaviours through an audit in primary care of screening attendance. Second, we interviewed patients (n = 47) and HCP (n = 30), to identify determinants of uptake using the Theoretical Domains Framework, mapping these to behaviour change techniques (BCTs) to develop intervention content. Thirdly, we conducted semi-structured consensus groups with stakeholders, specifically users of the intervention, i.e. patients (n = 15) and HCPs (n = 16), regarding the feasibility, acceptability, and local relevance of selected BCTs and potential delivery modes. We consulted representatives from the national DRS programme to check intervention 'fit' with existing processes. We applied the APEASE criteria (affordability, practicability, effectiveness, acceptability, side effects, and equity) to select the final intervention components, drawing on findings from the previous steps, and a rapid evidence review of operationalised BCT effectiveness.

RESULTS

We identified potentially modifiable target behaviours at the patient (consent, attendance) and professional (registration) level. Patient barriers to consent/attendance included confusion between screening and routine eye checks, and fear of a negative result. Enablers included a recommendation from friends/family or professionals and recognising screening importance. Professional barriers to registration included the time to register patients and a lack of readily available information on uptake in their local area/practice. Most operationalised BCTs were acceptable to patients and HCPs while the response to feasibility varied. After considering APEASE, the core intervention, incorporating a range of BCTs, involved audit/feedback, electronic prompts targeting professionals, HCP-endorsed reminders (face-to-face, by phone and letter), and an information leaflet for patients.

CONCLUSIONS

Using the example of an intervention to improve DRS uptake, this study illustrates an approach to integrate theory with user involvement. This process highlighted tensions between theory-informed and stakeholder suggestions, and the need to apply the Theoretical Domains Framework (TDF)/BCT structure flexibly. The final intervention draws on the trusted professional-patient relationship, leveraging existing services to enhance implementation of the DRS programme. Intervention feasibility in primary care will be evaluated in a randomised cluster pilot trial.

Feasibility of an implementation intervention to increase attendance at diabetic retinopathy screening: protocol for a cluster randomised pilot trial

BACKGROUND

Diabetic retinopathy screening (DRS) leads to the earlier detection of retinopathy and treatment that can prevent or delay the development of diabetes-related blindness. However, uptake continues to be sub-optimal in many countries, including Ireland. Routine management of type 2 diabetes largely takes place in primary care. As such, there may be an opportunity in primary care to introduce interventions to improve DRS uptake. However, few studies test the feasibility of interventions to enhance DRS uptake in this context. Our aim is to investigate the feasibility of an implementation intervention (IDEAs (Improving Diabetes Eye screening Attendance)) delivered in general practice to improve the uptake of the national DRS programme, RetinaScreen.

METHODS

The IDEAs study is a cluster randomised pilot trial with an embedded process evaluation and economic evaluation. Following stratification by practice size, eight general practices (clusters) will be randomly allocated to intervention (n = 4) or wait-list control groups (n = 4). The intervention will be delivered for 6 months, after which, it will be administered to wait-list control practices. The intervention is multi-faceted and comprises provider-level components (training, audit and feedback, health care professional prompt, reimbursement) and patient-level components (GP-endorsed reminder with information leaflet delivered opportunistically face-to-face, and systematically by phone and letter). Patient inclusion criteria are type 1 or type 2 diabetes and DRS programme non-attendance. A multi-method approach will be used to determine screening uptake, evaluate the trial and study procedures and examine the acceptability and feasibility of the intervention from staff and patient perspectives. Quantitative and qualitative data will be collected on intervention uptake and delivery, research processes and outcomes. Data will be collected at the practice, health professional and patient level. A partial economic evaluation will be conducted to estimate the cost of delivering the implementation intervention in general practice. Formal continuation criteria will be used to determine whether IDEAs should progress to a definitive trial.

DISCUSSION

Findings will determine whether IDEAsis feasible and acceptable and will be used to refine the intervention and study procedures. A definitive trial will determine whether IDEAs is a cost-effective intervention to improve DRS uptake and reduce diabetes-related blindness.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03901898. Registered 3rd April 2019.

Understanding the uptake of a national retinopathy screening programme: An audit of people with diabetes in two large primary care centres

Background: Diabetic retinopathy (DR) is estimated to affect 25–26% of the Irish population with diabetes and is one of the leading causes of blindness among working-age adults. Regular diabetic retinopathy screening (DRS) can reduce the risk of sight loss. In 2013, the new national screening programme (RetinaScreen) was introduced in Ireland. Maximising DRS uptake (consent to participate in the programme and attendance once invited) is a priority, therefore it is important to identify characteristics which determine DRS uptake among those with diabetes in Ireland. We report uptake in an Irish primary care population during the initial phase of implementation of RetinaScreen and investigate factors which predict consenting to participate in the programme. Methods: In two primary care practices, data were extracted from records of people with diabetes (type 1 and type 2) aged ≥18 years who were eligible to participate in RetinaScreen between November 2013 and August 2015. Records were checked for a RetinaScreen letter. RetinaScreen were contacted to establish the status of those without a letter on file. Multivariable Poisson regression was used to examine associations between socio-demographic variables and consenting. Adjusted incident rate ratios (IRR) with 95% CI were generated as a measure of association. Results: Of 722 people with diabetes, one fifth (n=141) were not registered with RetinaScreen. Of 582 who were registered, 63% (n=365) had participated in screening. Most people who consented subsequently attended (n=365/382, 96%). People who had attended another retinopathy screening service were less likely to consent (IRR 0.65 [95%CI 0.5-0.8]; p<0.001). Other predictors were not significantly associated with consent. Conclusions: Over one third of eligible participants in RetinaScreen had not consented. Research is needed to understand barriers and enablers of DRS uptake in the Irish context. Implementing strategies to improve DRS uptake, barriers to consent in particular, should be a priority.

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.

Understanding the uptake of a national retinopathy screening programme: An audit of patients with diabetes in two large primary care centres

Background: Diabetic retinopathy (DR) affects 8.2% of the Irish population with type 2 diabetes over 50 years and is one of the leading causes of blindness among working-age adults. Regular diabetic retinopathy screening (DRS) can reduce the risk of sight loss. In 2013, the new national screening programme (RetinaScreen) was introduced in Ireland. Maximising DRS uptake (consent to participate in the programme and attendance once invited) is a priority, therefore it is important to identify characteristics which determine DRS uptake among those with diabetes in Ireland. We report uptake in an Irish primary care population during the initial phase of implementation of RetinaScreen and investigate factors which predict consenting to participate in the programme. Methods:  In two primary care practices, data were extracted from records of people with diabetes (type 1 and type 2) aged ≥18 years who were eligible to participate in RetinaScreen between November 2013 and August 2015. Records were checked for a RetinaScreen letter. RetinaScreen were contacted to establish the status of those without a letter on file. Multivariable Poisson regression was used to examine associations between socio-demographic variables and consenting. Adjusted incident rate ratios (IRR) with 95% CI were generated as a measure of association. Results: Of 722 people with diabetes, one fifth (n=141) were not registered with RetinaScreen. Of 582 who were registered, 63% (n=365) had participated in screening. Most people who consented subsequently attended (n=365/382, 96%). People who had attended another retinopathy screening service were less likely to consent (IRR 0.65 [95%CI 0.5-0.8]; p<0.001). Other predictors were not significantly associated with consent. Conclusions: Over one third of people eligible to participate in RetinaScreen had not consented. Research is needed to understand barriers and enablers of DRS uptake in the Irish context. Implementing strategies to improve DRS uptake (consent and attendance) should be a priority.

Understanding the uptake of a national retinopathy screening programme: An audit of patients with diabetes in two large primary care centres

Background: Diabetic retinopathy (DR) affects 8.2% of the Irish population with type 2 diabetes over 50 years and is one of the leading causes of blindness among working-age adults. Regular diabetic retinopathy screening (DRS) can reduce the risk of sight loss. In 2013, the new national screening programme (RetinaScreen) was introduced in Ireland. Maximising DRS uptake (consent to participate in the programme and attendance once invited) is a priority, therefore it is important to identify characteristics which determine DRS uptake among those with diabetes in Ireland. We report uptake in an Irish primary care population during the initial phase of implementation of RetinaScreen and investigate factors which predict consenting to participate in the programme. Methods:  In two primary care practices, data were extracted from records of people with diabetes (type 1 and type 2) aged ≥18 years who were eligible to participate in RetinaScreen between November 2013 and August 2015. Records were checked for a RetinaScreen letter. RetinaScreen were contacted to establish the status of those without a letter on file. Multivariable Poisson regression was used to examine associations between socio-demographic variables and consenting. Adjusted incident rate ratios (IRR) with 95% CI were generated as a measure of association. Results: Of 722 people with diabetes, one fifth (n=141) were not registered with RetinaScreen. Of 582 who were registered, 63% (n=365) had participated in screening. Most people who consented subsequently attended (n=365/382, 96%). People who had attended another retinopathy screening service were less likely to consent (IRR 0.65 [95%CI 0.5-0.8]; p<0.001). Other predictors were not significantly associated with consent. Conclusions: Over one third of people eligible to participate in RetinaScreen had not consented. Research is needed to understand barriers and enablers of DRS uptake in the Irish context. Implementing strategies to improve DRS uptake (consent and attendance) should be a priority.

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).

The effect of geodemographic factors on the attendance rates at a regional diabetic retinopathy treatment centre

AIM

To determine whether geodemographic factors, specifically age, gender or commuting distance, affect the attendance rates of patients referred to a Diabetic Retinopathy Treatment (DRT) Centre from the Irish National Diabetic Retinal Screening (DRS) Programme.

METHODS

A retrospective analysis of the first 1200 patients who were referred for ophthalmic assessment between November 2013 and June 2015 to Cork University Hospital's (CUH) DRT clinic from the DRS was completed.

RESULTS

A total of 972 (81%) patients attended all their scheduled DRT appointments. The attendance rates for those living in counties Cork and Kerry were 83.9% and 72.5%, respectively. Fifty-seven (4.75%) patients failed to attend any of their clinic appointments (2.2% of Cork and 11.8% of Kerry referrals). Patients living within 60 km of the treatment centre were more likely to attend (p = 0.013). Both age and gender were also shown to have a statistically significant impact on attendance, with those under 40 years of age (p < 0.001) and male patients (p = 0.02) less likely to attend their scheduled appointments.

CONCLUSION

This study suggests a correlation between geodemographic factors (age, gender and commuting distance) and attendance at a DRT Centre. The longer commuting distance for Kerry patients contributes to their higher non-attendance rates indicating a need to provide a Kerry-based satellite treatment centre to improve accessibility.

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.

Trends in Blind and Low Vision Registrations in Taipei City

Purpose

To determine the overall reported incidence and causes of registrable blindness and low vision in Taipei, Taiwan, that have occurred in the previous 10 years.

Methods

Study data were obtained from disability identification registration forms completed between January 1995 and December 2004. Definitions of low vision and blindness were defined by WHO criteria: low vision included visual acuity worse than 6/18 (20/60) to a lower limit of 3/60 (20/400). Blindness was defined as visual acuity worse than 3/60 (20/400) in the better eye with best possible correction.

Results

There were 3151 registrations for visual impairment during the study period. A total of 239 registrations were excluded due to insufficient data. Of the remaining 2912 (1518 males and 1394 females), 640 males and 647 females were legally blind (44.20%). A total of 878 males and 747 females were partially sighted. The six leading causes of low vision and blindness, in decreasing frequency, were glaucoma, optic neuropathy, diabetic retinopathy, retinitis pigmentosa, age-related macular degeneration, and myopic macular degeneration.

Conclusions

The proportions of new registrations owing to glaucoma, diabetic retinopathy, age-related macular degeneration, and myopic macular degeneration have changed significantly since 2000; the proportion due to diabetic retinopathy has increased.

The Status of Maculopathy in Diabetes and Prediabetes Patients in a Population-Based Study Detected by Optical Coherence Tomography: The 2011 Health Examination Survey in Beijing

Objective

The aim of the study was to investigate the prevalence and the risk factors of maculopathy detected by optical coherence tomography (OCT) in a Chinese population with diabetes or prediabetes. Methods. 8,155 people were randomly selected to participate in the 2011 annual Health Examination Survey in Beijing. A 75 g oral glucose tolerance test (OGTT) was tested in 3760 subjects with fasting plasma glucose (FPG) ≥ 5.6 mmol/L. Of 3,760 subjects, 583 were also randomly selected to take OCT.

Results

In this study population, 21 (3.95%) patients had maculopathy. Eight patients had diabetes macular edema (DME) and the prevalence was 6.72% in diabetes patients and 1.51% in all subjects. Eleven patients had age-related macular degeneration (AMD) and the prevalence was 3.36% in diabetes patients and 2.07% in all subjects. Logistic regression model confirmed that elevated HbA1c (p < 0.001) and systolic pressure (p < 0.05) made significant contributions to DME. Stepwise regression analysis revealed that HbA1c and blood creatinine were significantly independent influence factors for central subfield thickness (CST) (p = 0.01, p < 0.001).

Conclusions

High prevalence of maculopathy was found in patients with diabetes in a Chinese population. Maculopathy poses a significant public health problem in China with rapid rising trend of diabetes.

Trends in blindness due to diabetic retinopathy among adults aged 18-69years over a decade in Ireland

AIMS

To describe trends in the incidence of visual impairment and blindness due to diabetic retinopathy among adults aged 18-69years in Ireland between 2004 and 2013.

METHODS

Data on visual impairment due to diabetic retinopathy in adults aged 18-69years or over who are registered with the National Council for the Blind of Ireland, (2004-2013) were analysed. Annual incidence rates were calculated for the adult population and the population with diagnosed diabetes. Poisson regression was used to test for changes in rates over time. The relative, attributable and population risk of blindness and visual impairment due to diabetic retinopathy were calculated for 2013.

RESULTS

Over the decade, the prevalence of diagnosed diabetes increased from 2.1% to 3.6%. Among people with diagnosed diabetes, the incidence of visual impairment due to diabetic retinopathy increased from 6.4 (95% CI 2.4-13.9) per 100,000 in 2004 to 11.7 (95% CI 5.9-21.0) per 100,000 in 2013. The incidence of blindness due to diabetic retinopathy varied from 31.9 per 100,000 (95% CI 21.6-45.7) in 2004 to 14.9 per 100,000 (95% CI 8.2-25.1) in 2013.

CONCLUSIONS

Our findings indicate the need for increased attention to preventive measures for microvascular complications among adults with diabetes in Ireland. Retinopathy screening has been standardised in Ireland, these findings provide useful baseline statistics to monitor the impact of this population-based screening programme.

[Incidence and causes of visual impairment in the district of Mahdia, in east Tunisia: Retrospective study of 1487 cases]

OBJECTIVE

To study socio-demographic characteristics and main causes related to visual impairment (VI) as a function of age bracket and to analyze their trends over time in the district of Mahdia.

METHOD

A retrospective review was performed on 1487 cases of visual impairment registered with the social authorities in Mahdia, between 1980 and 2013. The social, demographic, vision exam findings and causes were ascertained and analyzed in an SPSS database. Incidence rates of VI and blindness due to various causes were calculated based on the demographic data from the NSI to estimate the time trends using the general linear regression model and Spearman correlation.

RESULTS

Analyses included 1487 participants with a median age of 47 years, 40.6% of cases were aged under 45 years. Children accounted for 11.1% (165 patients), while age was between 16 and 45 years in 29.5% (439 patients), between 46 and 65 years in 31.5% (469 patients) and greater than 65 years in 27.8% (414 patients). The sex-ratio (M/F) was 1.78. Socially, 51% came from rural areas, 62% were illiterate, and 84% were unemployed. We observed blindness in 70% of participants and low vision in 30%. In children, the causes were dominated by congenital cataract and congenital glaucoma, each present in 31 children (18.8%). Between 16 and 45 years, glaucoma and hereditary dystrophies of the retina were found in 62 and 61 patients respectively (14% each). For age between 46 and 65 years, trachoma was responsible for 19.8% of cases of VI, glaucoma in 15.8% and cataract in 15.1%. Beyond 65 years, glaucoma accounted for 30.7% of the causes of VI and cataract 27.8% of cases. Trend analysis shows a significant increase in the incidence rate of visual impairment with an average of 12% per year (P=0.001). The mean age increased by 46% (P=0.003). Trachoma increased by 118% (P<0.0001) between 1980 and 1990, then declined by 42% (P=0.0013) between 1991 and 2013. Incidence of VI significantly increased by 4% for cataract (P=0.001), 23% (P=0.001) for glaucoma and 20% (P=0.02) for diabetic retinopathy, while VI related to refractive errors and AMD showed no significant change.

CONCLUSION

Advanced age, lower educational and socio-economic status were associated with bilateral VI. Age related eye problems are the main causes of VI, and their incidence is tending to increase. Public health policies and procedures should be targeted to risk related populations and age-related diseases in order to control the incidence of visual impairment and avoid its consequences.

Automated imaging technologies for the diagnosis of glaucoma: a comparative diagnostic study for the evaluation of the diagnostic accuracy, performance as triage tests and cost-effectiveness (GATE study)

BACKGROUND

Many glaucoma referrals from the community to hospital eye services are unnecessary. Imaging technologies can potentially be useful to triage this population.

OBJECTIVES

To assess the diagnostic performance and cost-effectiveness of imaging technologies as triage tests for identifying people with glaucoma.

DESIGN

Within-patient comparative diagnostic accuracy study. Markov economic model comparing the cost-effectiveness of a triage test with usual care.

SETTING

Secondary care.

PARTICIPANTS

Adults referred from the community to hospital eye services for possible glaucoma.

INTERVENTIONS

Heidelberg Retinal Tomography (HRT), including two diagnostic algorithms, glaucoma probability score (HRT-GPS) and Moorfields regression analysis (HRT-MRA); scanning laser polarimetry [glaucoma diagnostics (GDx)]; and optical coherence tomography (OCT). The reference standard was clinical examination by a consultant ophthalmologist with glaucoma expertise including visual field testing and intraocular pressure (IOP) measurement.

MAIN OUTCOME MEASURES

(1) Diagnostic performance of imaging, using data from the eye with most severe disease. (2) Composite triage test performance (imaging test, IOP measurement and visual acuity measurement), using data from both eyes, in correctly identifying clinical management decisions, that is 'discharge' or 'do not discharge'. Outcome measures were sensitivity, specificity and incremental cost per quality-adjusted life-year (QALY).

RESULTS

Data from 943 of 955 participants were included in the analysis. The average age was 60.5 years (standard deviation 13.8 years) and 51.1% were females. Glaucoma was diagnosed by the clinician in at least one eye in 16.8% of participants; 37.9% of participants were discharged after the first visit. Regarding diagnosing glaucoma, HRT-MRA had the highest sensitivity [87.0%, 95% confidence interval (CI) 80.2% to 92.1%] but the lowest specificity (63.9%, 95% CI 60.2% to 67.4%) and GDx had the lowest sensitivity (35.1%, 95% CI 27.0% to 43.8%) but the highest specificity (97.2%, 95% CI 95.6% to 98.3%). HRT-GPS had sensitivity of 81.5% (95% CI 73.9% to 87.6%) and specificity of 67.7% (95% CI 64.2% to 71.2%) and OCT had sensitivity of 76.9% (95% CI 69.2% to 83.4%) and specificity of 78.5% (95% CI 75.4% to 81.4%). Regarding triage accuracy, triage using HRT-GPS had the highest sensitivity (86.0%, 95% CI 82.8% to 88.7%) but the lowest specificity (39.1%, 95% CI 34.0% to 44.5%), GDx had the lowest sensitivity (64.7%, 95% CI 60.7% to 68.7%) but the highest specificity (53.6%, 95% CI 48.2% to 58.9%). Introducing a composite triage station into the referral pathway to identify appropriate referrals was cost-effective. All triage strategies resulted in a cost reduction compared with standard care (consultant-led diagnosis) but with an associated reduction in effectiveness. GDx was the least costly and least effective strategy. OCT and HRT-GPS were not cost-effective. Compared with GDx, the cost per QALY gained for HRT-MRA is £22,904. The cost per QALY gained with current practice is £156,985 compared with HRT-MRA. Large savings could be made by implementing HRT-MRA but some benefit to patients will be forgone. The results were sensitive to the triage costs.

CONCLUSIONS

Automated imaging can be effective to aid glaucoma diagnosis among individuals referred from the community to hospital eye services. A model of care using a triage composite test appears to be cost-effective.

FUTURE WORK

There are uncertainties about glaucoma progression under routine care and the cost of providing health care. The acceptability of implementing a triage test needs to be explored.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The Prevalence of Visual Impairment in People with Dementia (the PrOVIDe study): a cross-sectional study of people aged 60–89 years with dementia and qualitative exploration of individual, carer and professional perspectives

Background

The prevalence of visual impairment (VI) and dementia increases with age and these conditions may coexist, but few UK data exist on VI among people with dementia.

Objectives

To measure the prevalence of eye conditions causing VI in people with dementia and to identify/describe reasons for underdetection or inappropriate management.

Design

Stage 1 – cross-sectional prevalence study. Stage 2 – qualitative research exploring participant, carer and professional perspectives of eye care.

Setting

Stage 1 – 20 NHS sites in six English regions. Stage 2 – six English regions.

Participants

Stage 1 – 708 participants with dementia (aged 60–89 years): 389 lived in the community (group 1) and 319 lived in care homes (group 2). Stage 2 – 119 participants.

Interventions

Stage 1 gathered eye examination data following domiciliary sight tests complying with General Ophthalmic Services requirements and professional guidelines. Cognitive impairment was assessed using the Standardised Mini-Mental State Examination (sMMSE) test, and functional ability and behaviour were assessed using the Bristol Activities of Daily Living Scale and Cambridge Behavioural Inventory – Revised. Stage 2 involved individual interviews (36 people with dementia and 11 care workers); and separate focus groups (34 optometrists; 38 family and professional carers).

Main outcome measures.

VI defined by visual acuity (VA) worse than 6/12 or worse than 6/18 measured before and after refraction.

Results

Stage 1 – when participants wore their current spectacles, VI prevalence was 32.5% [95% confidence interval (CI) 28.7% to 36.5%] and 16.3% (95% CI 13.5% to 19.6%) for commonly used criteria for VI of VA worse than 6/12 and 6/18, respectively. Of those with VI, 44% (VA < 6/12) and 47% (VA < 6/18) were correctable with new spectacles. Almost 50% of remaining uncorrectable VI (VA < 6/12) was associated with cataract, and was, therefore, potentially remediable, and one-third was associated with macular degeneration. Uncorrected/undercorrected VI prevalence (VA < 6/12) was significantly higher in participants in care homes (odds ratio 2.19, 95% CI 1.30 to 3.73;p < 0.01) when adjusted for age, sex and sMMSE score. VA could not be measured in 2.6% of group 1 and 34.2% of group 2 participants (p < 0.01). The main eye examination elements (excluding visual fields) could be performed in > 80% of participants. There was no evidence that the management of VI in people with dementia differed from that in older people in general. Exploratory analysis suggested significant deficits in some vision-related aspects of function and behaviour in participants with VI. Stage 2 key messages – carers and care workers underestimated how much can be achieved in an eye examination. People with dementia and carers were unaware of domiciliary sight test availability. Improved communication is needed between optometrists and carers; optometrists should be informed of the person’s dementia. Tailoring eye examinations to individual needs includes allowing extra time. Optometrists wanted training and guidance about dementia. Correcting VI may improve the quality of life of people with dementia but should be weighed against the risks and burdens of undergoing examinations and cataract surgery on an individual basis.

Limitations

Sampling bias is possible owing to quota-sampling and response bias.

Conclusions

The prevalence of VI is disproportionately higher in people with dementia living in care homes. Almost 50% of presenting VI is correctable with spectacles, and more with cataract surgery. Areas for future research are the development of an eye-care pathway for people with dementia; assessment of the benefits of early cataract surgery; and research into the feasibility of specialist optometrists for older people.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The role of lamina cribrosa cells in optic nerve head fibrosis in glaucoma

Glaucoma is a chronic progressive optic neuropathy. There are extracellular matrix (ECM) changes associated with optic disc cupping in the optic nerve head (ONH) and subsequent visual field defects. The primary risk factor for onset and progression of glaucoma is raised intraocular pressure (IOP). Elevated IOP causes deformation at the ONH specifically at the lamina cribrosa (LC) region where there is also deposition of ECM causing the LC to initially undergo thickening and posterior migration with eventual shearing and collapse of the LC plates leading to a thin fibrotic connective tissue structure/scar. Cells that populate the LC region of the ONH are those cells that are positive for GFAP (the astrocytes) and those negative for GFAP (the LC cells). The LC cell plays an integral role in ECM remodelling producing ECM when exposed to high level mechanical stretch, TGF- β1 and a hypoxic environment.

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.

The Cost of Blindness in the Republic of Ireland 2010-2020

Aims. To estimate the prevalence of blindness in the Republic of Ireland and the associated financial and total economic cost between 2010 and 2020. Methods. Estimates for the prevalence of blindness in the Republic of Ireland were based on blindness registration data from the National Council for the Blind of Ireland. Estimates for the financial and total economic cost of blindness were based on the sum of direct and indirect healthcare and nonhealthcare costs. Results. We estimate that there were 12,995 blind individuals in Ireland in 2010 and in 2020 there will be 17,997. We estimate that the financial and total economic costs of blindness in the Republic of Ireland in 2010 were €276.6 million and €809 million, respectively, and will increase in 2020 to €367 million and €1.1 billion, respectively. Conclusions. Here, ninety-eight percent of the cost of blindness is borne by the Departments of Social Protection and Finance and not by the Department of Health as might initially be expected. Cost of illness studies should play a role in public policy making as they help to quantify the indirect or “hidden” costs of disability and so help to reveal the true cost of illness.

Epidemiology of diabetes and complications among adults in the Republic of Ireland 1998-2015: a systematic review and meta-analysis

Background

Accurate estimates of the burden of diabetes are essential for future planning and evaluation of services. In Ireland, there is no diabetes register and prevalence estimates vary. The aim of this review was to systematically identify and review studies reporting the prevalence of diabetes and complications among adults in Ireland between 1998 and 2015 and to examine trends in prevalence over time.

Methods

A systematic literature search was carried out using PubMed and Embase. Diabetes prevalence estimates were pooled by random-effects meta-analysis. Poisson regression was carried out using data from four nationally representative studies to calculate prevalence rates of doctor diagnosed diabetes between 1998 and 2015 and was also used to assess whether the rate of doctor diagnosed diabetes changed over time.

Results

Fifteen studies (eight diabetes prevalence and seven complication prevalence) were eligible for inclusion. In adults aged 18 years and over, the national prevalence of doctor diagnosed diabetes significantly increased from 2.2 % in 1998 to 5.2 % in 2015 (p_trend ≤ 0.001). The prevalence of diabetes complications ranged widely depending on study population and methodology used (6.5–25.2 % retinopathy; 3.2–32.0 % neuropathy; 2.5-5.2 % nephropathy).

Conclusions

Between 1998 and 2015, there was a significant increase in the prevalence of doctor diagnosed diabetes among adults in Ireland. Trends in microvascular and macrovascular complications prevalence could not be examined due to heterogeneity between studies and the limited availability of data. Reliable baseline data are needed to monitor improvements in care over time at a national level. A comprehensive national diabetes register is urgently needed in Ireland.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-2818-2) contains supplementary material, which is available to authorized users.

The prevalence and causes of visual impairment in young Turkish men

Objective:

To explore the causes and prevalence of visual impairment in young Turkish men.

Methods:

The health examination data of the candidates that are saved in National Defense Ministry of Turkey was used. The data of the candidates examined between 1 January 2009 and 31 December 2011 were evaluated. The total number of the candidates was 1777500. The candidates requiring advanced examination are referred to secondary and tertiary examination hospitals.

Results:

Fourteen thousand eight hundred sixty two(14862) out of 1777500 candidates were declared unfit for compulsory military service because of ophthalmic causes. The prevalence of ophthalmologic diseases causing unfitness for military service was found 0.746% for 2009, 0.871% for 2010 and 0.889% for 2011. These included high refractive errors which was the most frequent pathology causing unfitness (40.1%). Nonsurgical retina, vitreous and optic nerve diseases were the most frequent cause of visual impairment (0.212%). Corneal and lens pathologies were the second most frequent cause of blindness (0.101%).

Conclusions:

The data bank in National Defense Ministry analyzed in this study is not directly intended to explore the causes and prevalence of visual impairment in Turkey. However this study gives considerable knowledge about the causes and prevalence of visual impairment in Turkey.

The Function of Matricellular Proteins in the Lamina Cribrosa and Trabecular Meshwork in Glaucoma

PURPOSE

To review the current literature regarding the role of matricellular proteins in glaucoma, specifically in the lamina cribrosa (LC) region of the optic nerve head (ONH) and the trabecular meshwork (TM).

METHODS

A literature search was performed for published articles describing the expression and function of matricellular proteins such as thrombospondin (TSP), connective tissue growth factor (CTGF), secreted protein acidic and rich in cysteine (SPARC), and periostin in glaucoma.

RESULTS

In glaucoma, there are characteristic extracellular matrix (ECM) changes associated with optic disc cupping in the ONH and subsequent visual field defects. Matricellular proteins are a family of nonstructural secreted glycoproteins, which enable cells to communicate with their surrounding ECM, including CTGF, also known as CCN2, TSPs, SPARC, periostin, osteonectin, and tenascin-C and -X, and other ECM proteins. Such proteins appear to play a role in fibrosis and increased ECM deposition. Importantly, most are widely expressed in tissues particularly in the TM and ONH, and deficiency of TSP1 and SPARC has been shown to lower intraocular pressure in mouse models of glaucoma through enhanced outflow facility.

CONCLUSION

This article highlights the role of matricellular proteins in glaucoma pathology. The potential role of these proteins in glaucoma is emerging as some have an association with the pathophysiology of the TM and LC region and might therefore be potential targets for therapeutic intervention in glaucoma.

Supplementation with three different macular carotenoid formulations in patients with early age-related macular degeneration

PURPOSE

To investigate the impact of three different macular carotenoid formulations on macular pigment optical density and visual performance in subjects with early age-related macular degeneration.

METHODS

Fifty-two subjects were supplemented and followed for 12 months, 17 of them were in intervention Group 1 (20 mg/day lutein and 2 mg/day zeaxanthin); 21 in Group 2 (10 mg/day meso-zeaxanthin, 10 mg/day lutein, and 2 mg/day zeaxanthin); and 14 in Group 3 (17 mg/day meso-zeaxanthin, 3 mg/day lutein, and 2 mg/day zeaxanthin). The macular pigment optical density was measured using customized heterochromatic flicker photometry, and visual function was assessed using corrected distance visual acuity and by letter contrast sensitivity.

RESULTS

A statistically significant increase in the macular pigment optical density was observed at all measured eccentricities in Group 2 (P ≤ 0.005) and in Group 3 (P < 0.05, for all), but only at 1.75° in Group 1 (P = 0.018). Statistically significant (P < 0.05) improvements in letter contrast sensitivity were seen at all spatial frequencies (except 1.2 cycles per degree) in Group 3, and at low spatial frequencies in Groups 1 and 2.

CONCLUSION

Augmentation of the macular pigment optical density across its spatial profile and enhancements in contrast sensitivity were best achieved after supplementation with a formulation containing high doses of meso-zeaxanthin in combination with lutein and zeaxanthin.

Prevalence of age-related macular degeneration in the Republic of Ireland

Background

Age-related macular degeneration (AMD) remains the most common cause of visual loss among subjects over 50 years of age in the developed world. The Irish Longitudinal study on Ageing (TILDA) is a population-based study of subjects aged 50 years or older, designed to investigate factors that influence ageing, and has enabled this investigation of the prevalence of AMD in the Republic of Ireland (ROI).

Methods

Data collected from a nationally representative sample of community-living older adults aged 50 years and over in ROI over the period November 2009 to July 2011. 5035 participants attended the TILDA health centre for assessment. Retinal photographs were obtained in 4859 of these participants. Retinal grading was performed in a masked fashion using a modified version of the International Classification and Grading System for AMD.

Results

Adjusting for lower response rates among older subjects, the estimated overall prevalence of any AMD was 7.2% (95% CI 6.5% to 7.9%) in the population aged 50 years or older. The estimated prevalence of early AMD was 6.6% (95% CI 5.9% to 7.3%), and the estimated prevalence of late AMD was 0.6% (95% CI 0.4% to 0.8%). Statistically significant associations with AMD included increasing age and family history of the condition.

Conclusions

This is the first study to provide prevalence estimates of AMD in ROI and will inform eye care professionals and policymakers involved in the delivery and planning of care for those afflicted with this condition.

Report on the creation of a diabetes register and retinopathy screening outcomes in the Mid-West of Ireland

BACKGROUND

With concerns that blind registration in Ireland due to diabetic retinopathy is continuing to rise, a structured retinopathy screening service is in the process of being rolled out nationally.

AIMS

To report on the validation process for creating a register of diabetics in the Mid-West of Ireland, and findings following retinopathy screening of a representative sample.

METHODS

National primary care databases were employed in generating provisional lists of diabetic patients in the Health Service Executive (HSE) Mid-West area. Subsequent engagement with the corresponding general practices over a three year period between 2010 and 2013 facilitated the validation of these lists. A summary of the retinopathy screening outcomes of 1,434 patients and pre-existing screening patterns is reported.

RESULTS

The number of patients on the Mid-West diabetes register to date is 11,126. Of the 1,434 patients screened, 288 (20.1 %) had background retinopathy, while 117 (8.2 %) had sight-threatening retinopathy. Seventeen (19.8 %) of the 86 patients identified with maculopathy required treatment with intravitreal injections. Of the 610 patients questioned about previous screening events, 389 (63.8 %) said they had undergone an ocular examination within the previous 12 months.

CONCLUSIONS

The HSE Mid-West has over 11,000 patients on its database ready to be screened by the national programme, with the treatment of maculopathy expected to have the largest impact on resources. Although the majority of patients are already undergoing screening in the community in an ad hoc fashion, the rates of sight-threatening retinopathy encountered highlight the timeliness of the full implementation of the national programme.

Blindness Registers as Epidemiological Tools for Public Health Planning: A Case Study in Belize

For public eye health programs, blindness registers can be an important tool for informing service planning. This study examines how the Belize Council for the Visually Impaired (BCVI) used its blindness register data to drive several public health interventions. Cross-sectional analysis was performed for all active registrants (n=1194) to determine the distribution of causes of registration according to age, sex, and geographical district. Cataract was the leading cause of registration (39.6%), followed by glaucoma (20.8%), diabetic retinopathy (10.2%), and childhood blindness (9.4%). The distribution of the causes of registration was fairly similar between men and women and across the various districts. However, in Stann Creek, whose population is largely of African descent, glaucoma exceeded cataract. For most causes, the majority of registrants were registered at age 50 or older. Follow-up was conducted four years later. Several interventions had been initiated, most notably bolstering cataract surgical services and creating screening programs for glaucoma and diabetic retinopathy. The register itself was also improved to maximize its utility for future use. While standardized surveys may be the most appropriate method of estimating population-based measures such as prevalence or incidence, the blindness register is still a valuable source of data for public health planning.

Suitability and repeatability of a photostress recovery test device, the macular degeneration detector (MDD-2), for diabetes and diabetic retinopathy assessment

BACKGROUND

Diabetic retinopathy can result in impaired photostress recovery time despite normal visual acuity and fundoscopic appearance. The Macular Degeneration Detector (MDD-2) is a novel flash photostress recovery time device. In this study, we examine the repeatability of the MDD-2 in normal and diabetic subjects.

METHODS

One hundred and ninety one (90 women, 101 men) subjects were recruited and divided into 1 of the 3 study groups (normal controls, n = 40; diabetes no retinopathy, n = 98; nonproliferative diabetic retinopathy, n = 53). Photostress recovery time was measured three times in the study eye using the MDD-2, each measurement separated by a 5-minute interval.

RESULTS

Repeated measures analysis of variance revealed no statistically significant learning or fatigue effects on intrameasurement repeatability for any group. Photostress recovery time measures were broadly similar and typically not statistically significantly different between study groups. The coefficient of repeatability reached clinically acceptable levels once the initial photostress recovery time measure, which demonstrated increased variability and latency compared with all subsequent measures, was excluded.

CONCLUSION

The MDD-2 seems to provide repeatable photostress recovery time measurements among naive diabetic subjects. The device does not, however, seem capable of differentiating normal and nonproliferative diabetic eyes, and would not be suitable for inclusion in diabetic retinopathy screening protocol.

The role of matricellular proteins in glaucoma

Glaucoma is an optic neuropathy affecting approximately 60million people worldwide and is the second most common cause of irreversible blindness. Elevated intraocular pressure (IOP) is the main risk factor for developing glaucoma and is caused by impaired aqueous humor drainage through the trabecular meshwork (TM) and Schlemm's canal (SC). In primary open angle glaucoma (POAG), this elevation in IOP in turn leads to deformation at the optic nerve head (ONH) specifically at the lamina cribrosa (LC) region where there is also a deposition of extracellular matrix (ECM) molecules such as collagen and fibronectin. Matricellular proteins are non-structural secreted glycoproteins that help cells communicate with their surrounding ECM. This family of proteins includes connective tissue growth factor (CTGF), also known as CCN2, thrombospondins (TSPs), secreted protein acidic and rich in cysteine (SPARC), periostin, osteonectin, and Tenascin-C and -X and other ECM proteins. All members appear to play a role in fibrosis and increased ECM deposition. Most are widely expressed in tissues particularly in the TM and ONH and deficiency of TSP1 and SPARC have been shown to lower IOP in mouse models of glaucoma through enhanced outflow facility. The role of these proteins in glaucoma is emerging as some have an association with the pathophysiology of the TM and LC regions and might therefore be potential targets for therapeutic intervention in glaucoma.

Quality-assured screening for diabetic retinopathy delivered in primary care in Ireland: an observational study

BACKGROUND

At present, there is no national population-based retinopathy screening programme for people in Ireland who have diabetes, such as those operating in the UK for over a decade.

AIM

To evaluate a community-based initiative that utilised existing resources in general practice and community optometry/ophthalmology services to provide screening for diabetic retinopathy.

DESIGN AND SETTING

Cross-sectional study using electronic ophthalmic patient screening records in community optometry clinics in Cork, Ireland.

METHOD

A purposive sample of 32 practices was recruited from Diabetes in General Practice, a general practice-led initiative in the South of Ireland. Practices invited all adult patients registered with diabetes to participate in free retinopathy screening (n = 3598), provided by 15 community optometry practices and two community ophthalmologists. Data were recorded on an electronic database used by optometrists and the performance was benchmarked against proposed national standards for retinopathy screening.

RESULT

In total, 30 practices participated (94%). After 6 months, 49% of patients (n = 1763) had been screened, following one invitation letter and no reminder. Forty-three per cent of those invited consented to their data being used in the study and subsequent analyses are based on that sample (n = 1542). The mean age of the patients screened was 65 years (standard deviation = 13.0 years), 57% were male (n = 884), and 86% had type 2 diabetes (n = 1320). In total, 26% had some level of retinopathy detected (n = 395); 21% had background retinopathy (n = 331), 3% had pre-proliferative retinopathy (n = 53), and 0.7% had proliferative retinopathy (n = 11).

CONCLUSION

The detection of retinopathy among 26% of those screened highlights the need for a national retinopathy screening programme in Ireland. Significant learning, derived from the implementation of this initiative, will inform the national programme.

Clinical applicability of the Macular Degeneration Detection Device (MDD-2): a novel photostress recovery measurement device

BACKGROUND

Diseases affecting the macula, such as age-related macular degeneration (AMD), diabetic retinopathy and central serous retinopathy can result in impaired photostress recovery time (PSRT) despite normal visual acuity and fundoscopic appearance. The MDD-2 Macular Degeneration Detection Device is a novel flash photostress recovery device. In this study, we examine the repeatability of the MDD-2 in a normal population and its suitability for incorporation into routine clinical practice.

METHODS

One hundred (60 female) subjects (mean age 35 ± 8 years; range 18 to 66 years) were recruited to partake in this study. The photostress recovery time was measured using the MDD-2 on three occasions in the dominant eye and one final occasion in the non-dominant eye to assess measurement repeatability. All subjects were in good ocular health. Visual acuity and iris colour were recorded for each participant.

RESULTS

Repeated measures analysis of variance revealed a statistically significant learning effect on intra-measurement repeatability (p < 0.01). Although paired t-test analysis revealed statistically significant differences between repeated measures both within and between eyes (p < 0.05 for all) the correlation between repeat measurements is statistically significant (p < 0.05 for all), and the coefficient of repeatability reaches clinically acceptable levels once the initial photostress recovery time, which demonstrated increased variability and latency compared to all subsequent measures, is excluded.

CONCLUSION

The MDD-2 provides highly repeatable measurements of photostress recovery time among young naïve subjects, following verbal explanation of the task and only one 'practise' measurement. The measurement is also highly repeatable between eyes, providing a potential immediate clinical biomarker of ocular health.

The complex interactions of retinal, optical and environmental factors in myopia aetiology

Myopia is the commonest ocular abnormality but as a research topic remains at the margins of mainstream ophthalmology. The concept that most myopes fall into the category of 'physiological myopia' undoubtedly contributes to this position. Yet detailed analysis of epidemiological data linking myopia with a range of ocular pathologies from glaucoma to retinal detachment demonstrates statistically significant disease association in the 0 to -6 D range of 'physiological myopia'. The calculated risks from myopia are comparable to those between hypertension, smoking and cardiovascular disease. In the case of myopic maculopathy and retinal detachment the risks are an order of magnitude greater. This finding highlights the potential benefits of interventions that can limit or prevent myopia progression. Our understanding of the regulatory processes that guide an eye to emmetropia and, conversely how the failure of such mechanisms can lead to refractive errors, is certainly incomplete but has grown enormously in the last few decades. Animal studies, observational clinical studies and more recently randomized clinical trials have demonstrated that the retinal image can influence the eye's growth. To date human intervention trials in myopia progression using optical means have had limited success but have been designed on the basis of simple hypotheses regarding the amount of defocus at the fovea. Recent animal studies, backed by observational clinical studies, have revealed that the mechanisms of optically guided eye growth are influenced by the retinal image across a wide area of the retina and not solely the fovea. Such results necessitate a fundamental shift in how refractive errors are defined. In the context of understanding eye growth a single sphero-cylindrical definition of foveal refraction is insufficient. Instead refractive error must be considered across the curved surface of the retina. This carries the consequence that local retinal image defocus can only be determined once the 3D structure of the viewed scene, off axis performance of the eye and eye shape has been accurately defined. This, in turn, introduces an under-appreciated level of complexity and interaction between the environment, ocular optics and eye shape that needs to be considered when planning and interpreting the results of clinical trials on myopia prevention.

Retinopathy and visual impairment in diabetes, impaired glucose tolerance and normal glucose tolerance: the Nord-Trøndelag Health Study (the HUNT study)

PURPOSE

The aim of the study was to describe the prevalence of visual impairment and retinopathy and to investigate risk factors for retinopathy in persons with diabetes, screen-detected diabetes, impaired glucose tolerance and normal glucose tolerance in a subpopulation of the HUNT study.

METHODS

We used a sample (n = 163) from a population-based screening survey of hyperglycaemia, undertaken in 2004-2005 in Verdal, Norway. Baseline information was accessible through the second Nord-Trøndelag Health Study (HUNT2), 1995-97. Data collection was made in 2005 and included patient history, refraction, visual acuity, cataract assessment and single-field, nonmydriatic retinal photography. Retinal photographs were graded independently by two graders blinded to patient information. Data were analysed with standard statistical methods, and p < 0.05 was considered significant.

RESULTS

In all, 126 (77%) persons participated, 55% were women. The mean (SD) age was 59 (± 14) years. Four (3%) had correctable visual impairment, and none were visually impaired. Retinal photographs were gradable for both eyes in 109 (87%) participants. The prevalence of retinopathy was 11% in persons with known diabetes, 4% in persons with screen-detected diabetes, 3% in persons with impaired glucose tolerance and 10% in persons with normal glucose tolerance. Retinopathy was not associated with known history of diabetes or current glycaemic status. Nonfasting plasma glucose (in 1995-97) was an independent risk factor for retinopathy (in 2005), OR (95% CI) 1.5 (1.01, 2.13), p = 0.046.

CONCLUSION

The prevalence of diabetic retinopathy in persons with diabetes in this study was low. Appropriate optical correction and regular eye examination can prevent unnecessary visual impairment in both persons with and without diabetes.

Oxidative stress, mitochondrial dysfunction and calcium overload in human lamina cribrosa cells from glaucoma donors

PURPOSE

Oxidative stress is implicit in the pathological changes associated with glaucoma. The purpose of this study was to compare levels of oxidative stress in glial fibrillary acid-negative protein (GFAP) lamina cribrosa (LC) cells obtained from the optic nerve head (ONH) region of 5 normal (NLC) and 4 glaucomatous (GLC) human donor eyes and to also examine mitochondrial function and calcium homeostasis in this region of the ONH.

METHODS

Intracellular reactive oxygen species (ROS) production was examined by a thiobarbituric acid reactive substances (TBARS) assay which measures malondialdehyde (MDA), a naturally occurring product of lipid peroxidation and is used as an indicator of oxidative stress. Mitochondrial membrane potential (MMP) and intracellular calcium ([Ca(2+)](i)) levels were evaluated by flow cytometry using the JC-1 (5,5',6,6'-tetrachloro-1,1',3,3'-tetrabenzimidazolecarbocyanine iodide) and fluo-4/AM probes respectively. Anti-oxidant and Ca(2+) transport system gene and protein expression were determined by real time polymerase chain reaction (RT-PCR) using gene-specific primer/probe sets and western immunoblotting, respectively.

RESULTS

Intracellular ROS production was increased in GLC compared to NLC (27.19 ± 7.05 µM MDA versus 14.59 ± 0.82 µM MDA, p < 0.05). Expression of the anti-oxidants Aldo-keto reductase family 1 member C1 (AKR1C1) and Glutamate cysteine ligase catalytic subunit (GCLC) were significantly lower in GLC (p = 0.02) compared to NLC control. MMP was lower in GLC (57.5 ± 6.8%) compared to NLC (41.8 ± 5.3%). [Ca(2+)](i) levels were found to be higher (p < 0.001) in GLC cells compared to NLC. Expression of the plasma membrane Ca(2+)/ATPase (PMCA) and the sodium-calcium (NCX) exchangers were lower, while intracellular sarco-endoplasmic reticulum Ca(2+)/ATPase 3 (SERCA) expression was significantly higher in GLC compared to NLC. Subjection of NLC cells to oxidative stress (200 µM H(2)0(2)) reduced expression of Na(+)/Ca2(+) exchanger 1 (NCX 1), plasma membrane Ca2+ ATPase 1 (PMCA 1), and PMCA 4 as determined by RT-PCR.

CONCLUSIONS

Our data finds evidence of oxidative stress, mitochondrial dysfunction and impaired calcium extrusion in GLC cells compared to NLC cells and suggests their importance in the pathological changes occurring at the ONH in glaucoma. Future therapies may target reducing oxidative stress and / or [Ca(2+)](i).

Causes and 3-year-incidence of blindness in Jing-An District, Shanghai, China 2001-2009

Background

Registered data can provide valuable information regarding blindness. The purpose of this study was to evaluate the main causes and 3-year incidence of registered blindness in Jing-An district in Shanghai, China.

Methods

Data from the blindness registry (age, gender and cause of visual disability) were collected and analyzed. The prevalence of blindness for 2003, 2007, 2009 and the 3-year incidence of blindness were calculated.

Results

The reported blindness increased significantly from 113.7 per 100,000 in 2003 to 145.8 per 100,000 in 2006 to 165.9 per 100,000 in 2009 (P < 0.05, P < 0.05, respectively). Age significantly affects prevalence; the odd ratios (OR) were 2.57 in the 30 y - 49 y range (P < 0.001), 7.27 in the 50 y - 69 y range (P < 0.001) and 21.2 in the ≥ 70 y (P < 0.001). The 3-year incidence increased from 32.3 per 100,000 in 2001-2003 to 34.2 per 100,000 in 2004-2006 to 40.8 per 100,000 in 2007-2009. The causes of new blindness registered in 2001-2009 were myopic macular degeneration (19.4%), followed by glaucoma (17.7%), age-related macular degeneration (11.8%), optical nerve atrophy (9.4%), retinitis pigmentosa (8.6%), diabetic retinopathy (7.8%) and corneal opacity (5.8%).

Conclusions

The 3-year incidence and prevalence of registered blindness increased in the past 9 years. The leading causes of new blindness were myopic macular degeneration, glaucoma and age-related macular degeneration. The pattern of causes has changed little in the past 9 years and is different from other locations in China. The pattern is similar to that of Taiwan, Hongkong, and Western countries.

Ocular findings among young men: a 12-year prevalence study of military service in Poland

PURPOSE

To determine the prevalence of ocular diseases among young men and to assess the main ocular causes reflecting discharge from military service in Poland.

METHODS

A retrospective review of the medical records of 105 017 men undergoing a preliminary examination for military service during the period 1993-2004. Sample size for the study was calculated with 99% confidence within an error margin of 5%. All of the study participants were White men of European origin, most of whom live or lived in Poland. Data regarding the vision status were assessed in 1938 eyes of 969 participants. Two groups were distinguished based on the age of the participants: group I aged 18-24 years, and group II aged 25-34 years.

RESULTS

Presented visual impairment [visual acuity (VA)<20/40)] followed by colour vision defects were the most common ocular disorders, accounting for 13.2%. There were statistically significant differences in uncorrected VA as well as in the rates of particular refractive errors in between the age groups (p<0.05). The prevalence of glaucoma and ocular hypertension was significantly higher in older participants. Six hundred and sixty-seven (68.8%) participants examined medically in the study period were accepted for military service. However, 302 (31.2%) failed their examination and were temporarily or permanently discharged from duty. Fifty-two of them (17.2%) were discharged because of various ocular disorders. The most common causes were high refractive errors, which accounted for 38.5% of all the ocular discharges, followed by chronic and recurrent diseases of the posterior segment of the eye, which accounted for 19.2%.

CONCLUSION

The prevalence of ocular disorders among young men in an unselected military population was closer to the results obtained in other population-based studies comprising both men and women in the same age group. High refractive errors followed by chronic and recurrent diseases of the posterior segment of the eye are important causes of medical discharges from military service in Poland.