How does age-related macular degeneration affect real-world visual ability and quality of life? A systematic review

Association of exposure to ultraviolet radiation and warm-season ozone air pollution with incident age-related macular degeneration: A nationwide cohort study in China

BACKGROUND

As the leading cause of blindness, age-related macular degeneration (AMD) performs an adverse impact on human health and disability. AMD have been reported to be associated with environmental factors; however, the association between ultraviolet (UV) radiation, warm-season ambient ozone pollution, and incident AMD remains unclear.

METHODS

In this study, 19,707 participants without AMD at baseline were included from a nationwide longitudinal cohort in China. UV radiation and warm-season ozone exposure were evaluated through satellite-based models. Incident AMD was diagnosed via ophthalmological fundus images. Cox proportional hazard regression models were employed to explore the association of UV radiation and warm-season ozone with incident AMD, and the hazard ratios (HRs) and 95 % confidence intervals (CIs) were reported.

RESULTS

During 312,935 person-month of follow-up, 3774 participants developed to AMD. High exposure to both UV radiation and warm-season ozone was associated with increasing risk of incident AMD, with HRs and 95 % CIs of 1.32 (1.23, 1.41) and 1.20 (1.11, 1.29) in two-exposure models, respectively. Moreover, negative interaction between UV radiation and warm-season ozone was identified, and it was found that exposure to high UV radiation and low ozone presented the highest hazard for AMD. Subgroup analyses showed that the UV-AMD association was stronger in southern China, while the ozone-AMD association was greater in northern China and rural areas.

CONCLUSION

Our study provides the first epidemiological evidence that both UV radiation and warm-season ozone would elevate the risk of incident AMD, and the hazard of higher UV radiation may be attenuated by exposure to ozone. Strategies for decreasing AMD burden should jointly consider environmental exposures and geographic locations.

Retinal sensitivity changes in early/intermediate AMD: a systematic review and meta-analysis of visual field testing under mesopic and scotopic lighting

Visual fields under mesopic and scotopic lighting are increasingly being used for macular functional assessment. This review evaluates its statistical significance and clinical relevance, and the optimal testing protocol for early/intermediate age-related macular degeneration (AMD). PubMed and Embase were searched from inception to 14/05/2022. All quality assessments were performed according to GRADE guidelines. The primary outcome was global mean sensitivity (MS), further meta-analysed by: AMD classification scheme, device, test pattern, mesopic/scotopic lighting, stimuli size/chromaticity, pupil dilation, testing radius (area), background luminance, adaptation time, AMD severity, reticular pseudodrusen presence, and follow-up visit. From 1489 studies screened, 42 observational study results contributed to the primary meta-analysis. Supported by moderate GRADE certainty of the evidence, global MS was significantly reduced across all devices under mesopic and scotopic lighting with large effect size (-0.9 [-1.04, -0.75] Hedge's g, P < 0.0001). The device (P < 0.01) and lighting (P < 0.05) used were the only modifiable factors affecting global MS, whereby the mesopic MP-1 and MAIA produced the largest effect sizes and exceeded test-retest variabilities. Global MS was significantly affected by AMD severity (intermediate versus early AMD; -0.58 [-0.88, -0.29] Hedge's g or -2.55 [3.62, -1.47] MAIA-dB) and at follow-up visit (versus baseline; -0.62 [-0.84, -0.41] Hedge's g or -1.61[-2.69, -0.54] MAIA-dB). Magnitudes of retinal sensitivity changes in early/intermediate AMD are clinically relevant for the MP-1 and MAIA devices under mesopic lighting within the central 10° radius. Other factors including pupil dilation and dark adaptation did not significantly affect global MS in early/intermediate AMD.

Age-related macular degeneration: suitability of optogenetic therapy for geographic atrophy

Age-related macular degeneration (AMD) is a growing public health concern given the aging population and it is the leading cause of blindness in developed countries, affecting individuals over the age of 55 years. AMD affects the retinal pigment epithelium (RPE) and Bruch's membrane in the macula, leading to secondary photoreceptor degeneration and eventual loss of central vision. Late AMD is divided into two forms: neovascular AMD and geographic atrophy (GA). GA accounts for around 60% of late AMD and has been the most challenging subtype to treat. Recent advances include approval of new intravitreally administered therapeutics, pegcetacoplan (Syfovre) and avacincaptad pegol (Iveric Bio), which target complement factors C3 and C5, respectively, which slow down the rate of enlargement of the area of atrophy. However, there is currently no treatment to reverse the central vision loss associated with GA. Optogenetics may provide a strategy for rescuing visual function in GA by imparting light-sensitivity to the surviving inner retina (i.e., retinal ganglion cells or bipolar cells). It takes advantage of residual inner retinal architecture to transmit visual stimuli along the visual pathway, while a wide range of photosensitive proteins are available for consideration. Herein, we review the anatomical changes in GA, discuss the suitability of optogenetic therapeutic sensors in different target cells in pre-clinical models, and consider the advantages and disadvantages of different routes of administration of therapeutic vectors.

Burden of Disease Study of Patients with Neovascular Age-Related Macular Degeneration in Spain

INTRODUCTION

Neovascular age-related macular degeneration (nAMD) is a progressive retinal disease that causes severe and irreversible vision loss. The disease can therefore have a significant impact on the life of patients' and their families. The aim of this study was to evaluate the socio-economic burden of nAMD in Spain.

METHODS

The annual cost per patient with nAMD was estimated for the first, second, and third year (or beyond) of treatment since diagnosis. Several cost categories were considered including direct healthcare costs (DHC), direct non-healthcare costs (DNHC), labor productivity losses (LPL), and intangible costs (IC) related to loss of quality of life. The average annual cost per patient was estimated by assigning a unit price or financial proxy to the resources consumed per patient. Reference year of costs was 2021.

RESULTS

The mean annual cost of nAMD was estimated at €17,265, €15,403, and €14,465 per patient in the first, second, and third year of treatment after diagnosis. There was an additional one-off cost of €744 associated with the diagnosis of nAMD. DHC accounted for most of the total annual cost per patient independent of the year of treatment since diagnosis (48% in year 1; 42% in year 2; 39% in year 3). Similarly, DNHC had an important contribution to the total costs (32% in year 1; 35% in year 2; 37% in year 3), followed by IC (20% in year 1; 23% in year 2; 24% in year 3), while the contribution of patients' LPL was minimal.

CONCLUSION

This study estimated a high economic burden associated with nAMD for patients and their families, the healthcare system, and society at large. There is a need to improve the management of these patients to reduce the impact of nAMD disease progression.

Home-monitoring for neovascular age-related macular degeneration in older adults within the UK: the MONARCH diagnostic accuracy study

Background

Most neovascular age-related macular degeneration treatments involve long-term follow-up of disease activity. Home monitoring would reduce the burden on patients and those they depend on for transport, and release clinic appointments for other patients. The study aimed to evaluate three home-monitoring tests for patients to use to detect active neovascular age-related macular degeneration compared with diagnosing active neovascular age-related macular degeneration by hospital follow-up.

Objectives

There were five objectives: Estimate the accuracy of three home-monitoring tests to detect active neovascular age-related macular degeneration. Determine the acceptability of home monitoring to patients and carers and adherence to home monitoring. Explore whether inequalities exist in recruitment, participants' ability to self-test and their adherence to weekly testing during follow-up. Provide pilot data about the accuracy of home monitoring to detect conversion to neovascular age-related macular degeneration in fellow eyes of patients with unilateral neovascular age-related macular degeneration. Describe challenges experienced when implementing home-monitoring tests.

Design

Diagnostic test accuracy cohort study, stratified by time since starting treatment.

Setting

Six United Kingdom Hospital Eye Service macular clinics (Belfast, Liverpool, Moorfields, James Paget, Southampton, Gloucester).

Participants

Patients with at least one study eye being monitored by hospital follow-up.

Reference standard

Detection of active neovascular age-related macular degeneration by an ophthalmologist at hospital follow-up.

Index tests

KeepSight Journal: paper-based near-vision tests presented as word puzzles. MyVisionTrack®: electronic test, viewed on a tablet device. MultiBit: electronic test, viewed on a tablet device. Participants provided test scores weekly. Raw scores between hospital follow-ups were summarised as averages.

Results

Two hundred and ninety-seven patients (mean age 74.9 years) took part. At least one hospital follow-up was available for 317 study eyes, including 9 second eyes that became eligible during follow-up, in 261 participants (1549 complete visits). Median testing frequency was three times/month. Estimated areas under receiver operating curves were < 0.6 for all index tests, and only KeepSight Journal summary score was significantly associated with the lesion activity (odds ratio = 3.48, 95% confidence interval 1.09 to 11.13, p = 0.036). Older age and worse deprivation for home address were associated with lower participation (χ2 = 50.5 and 24.3, respectively, p < 0.001) but not ability or adherence to self-testing. Areas under receiver operating curves appeared higher for conversion of fellow eyes to neovascular age-related macular degeneration (0.85 for KeepSight Journal) but were estimated with less precision. Almost half of participants called a study helpline, most often due to inability to test electronically.

Limitations

Pre-specified sample size not met; participants' difficulties using the devices; electronic tests not always available.

Conclusions

No index test provided adequate test accuracy to identify lesion diagnosed as active in follow-up clinics. If used to detect conversion, patients would still need to be monitored at hospital. Associations of older age and worse deprivation with study participation highlight the potential for inequities with such interventions. Provision of reliable electronic testing was challenging.

Future work

Future studies evaluating similar technologies should consider: Independent monitoring with clear stopping rules based on test performance. Deployment of apps on patients' own devices since providing devices did not reduce inequalities in participation and complicated home testing. Alternative methods to summarise multiple scores over the period preceding a follow-up.

Trial registration

This trial is registered as ISRCTN79058224.

Funding

This award was funded by the National Institute of Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 15/97/02) and is published in full in Health Technology Assessment; Vol. 28, No. 32. See the NIHR Funding and Awards website for further award information.

Recent daily life burdens associated with neovascular age-related macular degeneration involve difficulties in use of electronic devices

Neovascular age-related macular degeneration (nAMD) is a prevalent cause of permanent vision loss and blindness in the elderly worldwide, with a significant impact on patients' daily lives. However, burdens related to nAMD from the patients' perspective have not been well documented. Here we developed a new questionnaire after eliciting nAMD patients' daily challenges followed by a pilot survey. Seven daily life burden domains were identified, and a quantitative survey was conducted using the questionnaire in the real-world clinic. Of the total 153 participants (mean age, 76.3 ± 8.3 years), 67 (43.8%) had bilateral nAMD, and 79 (52.7%) were classified into severe nAMD according to the best-corrected visual acuity with cut-off value of 0.52 in logMAR. Patients with bilateral and severe nAMD had significantly higher burden scores across all domains. Network models for the bilateral and severe disease subgroups identified the interactions between "activity of daily living" and "hand-eye coordination" and between "use of electronic devices" and "face recognition" domains, which were considered to be important burdens for the patients. These results can advance ophthalmologists' understanding of the impact of nAMD on patients' daily lives and the importance of active and continuing treatment for patients with nAMD.

Association between low lung function and the increased risk of age-related macular degeneration: A population-based prospective cohort study

Background

Low lung function is associated with an increased risk of age-related diseases. However, the relationship between age-related macular degeneration (AMD), the leading cause of blindness, and lung function remains unclear. We aimed to investigate whether low lung function increases the risk of AMD and the potential mechanisms behind this association.

Methods

We conducted a prospective cohort analysis of 409 230 UK Biobank participants with completed lung function after excluding individuals with AMD. We used Cox proportional hazards models to estimate the risk of AMD incidence and mediation models to explore potential mechanisms driven by inflammatory markers, erythrocyte-related measures, and metabolites.

Results

Overall, 6477 AMD cases were diagnosed across an average of 12.4 years of follow-up. Participants with low lung function had an increased risk of developing AMD compared to those with high lung function (forced vital capacity: adjusted hazard ratio (aHR) = 1.20 (95% confidence interval (CI) = 1.07-1.34); forced expiratory volume in one second: aHR = 1.32 (95% CI = 1.18-1.47); peak expiratory flow: aHR = 1.32 (95% CI = 1.20-1.45)). Inflammatory markers and erythrocyte-related measures mediated this relationship, acting as a pathway through which low lung function influenced AMD. The interactions of body mass index (BMI), sex, and smoking were significant and the effect of lung function on AMD was higher in men, obese, and smoking populations.

Conclusions

The increased risk of AMD was associated with low lung function, with inflammatory and erythrocyte-related markers mediating this relationship. This suggests that improvements in lung function could reduce the risk of AMD, thereby promoting health and longevity.

Development and Validation of Performance-Based Assessment of Daily Living Tasks in Age-Related Macular Degeneration

Purpose

To establish the reliability and validity of five performance-based activities of daily living task tests (ADLTT), to correlate structure to function, to evaluate the impact of visual impairment (VI) on age-related macular degeneration (AMD), and to develop new outcome measures.

Methods

A multidisciplinary team developed five ADLTTs: (1) reading test (RT); (2) facial expression (FE) recognition; (3) item search (IS) task; (4) money counting (MC) task; and (5) making a drink (MD), tested with binocular and monocular vision. ADLTTs were tested for known-group (i.e., difference between AMD group and controls) and convergent (i.e., correlation to other measures of visual function), validity metrics, and test-retest reliability in 36 patients with VI (visual acuity (logMAR VA > 0.4) in at least one eye caused by AMD versus 36 healthy controls without VI.

Results

Compared to controls, AMD patients had a slower reading speed (-77.41 words/min; P < 0.001); took longer to complete MC using monocular worse eye and binocular vision (15.13 seconds and 4.06 seconds longer compared to controls, respectively; P < 0.001); and MD using monocular worse eye vision (9.37 sec; P = 0.033), demonstrating known-group validity. Only RT and MC demonstrated convergent validity, showing correlations with VA, contrast sensitivity, and microperimetry testing. Moderate to good test-retest reliability was observed for MC and MD (interclass correlation coefficient = 0.55 and 0.77; P < 0.001) using monocular worse eye vision.

Conclusions

Real-world ADL functioning associated with VI-related AMD can be assessed with our validated ADLTTs, particularly MC and MD.

Translational Relevance

This study validates visual function outcome measures that are developed for use in future clinical practice and clinical trials.

Prevalence and risk factors for impaired activities of daily living in patients with neo-vascular age-related macular degeneration who present for anti-VEGF treatment

BACKGROUND/OBJECTIVES

To assess the prevalence and correlates of impaired activities of daily living (ADLs) in patients with neovascular age-related macular degeneration (nAMD) who present for anti-vascular endothelial growth factor (VEGF) therapy.

METHODS

In a clinic-based cohort of 437 patients with nAMD who presented for anti-VEGF therapy, the Older American Resources and Services Scale (OARS) was administered to assess for impairments in basic, instrumental and total ADL. Logistic regression analyses were conducted to determine odds ratios (OR) and 95% confidence intervals (CI) for factors associated with ADL impairment.

RESULTS

The prevalence of impaired basic, instrumental and total ADL was 37.76%, 67.82% and 39.59%, respectively. In multivariate-adjusted models, moderate visual impairment [OR 5.65, 95% CI (2.31-13.83) and blindness [OR 5.43, 95% CI (2.09-14.12)] were associated with greater odds of impaired total ADL. Depressive symptoms [OR 2.08, 95% CI (1.08-4.00)], the presence of any disability [OR 3.16, 95% CI (1.64-0.07)] and never driving [OR 4.00, 95% CI (1.60-10.00)] were also positively associated with total ADL impairment. Better vision-related quality of life (QoL) was inversely associated with impaired instrumental ADL whilst higher health-related QoL scores were associated with decreased odds of total ADL impairment.

CONCLUSIONS

There is a high prevalence rate of ADL impairment among nAMD patients presenting for therapy. Visual impairment, never driving, poor physical and mental health increased the odds of experiencing ADL impairment whilst better VRQoL and HRQoL reduced the odds of impairment.

Human versus Artificial Intelligence: Validation of a Deep Learning Model for Retinal Layer and Fluid Segmentation in Optical Coherence Tomography Images from Patients with Age-Related Macular Degeneration

Artificial intelligence (AI) models have received considerable attention in recent years for their ability to identify optical coherence tomography (OCT) biomarkers with clinical diagnostic potential and predict disease progression. This study aims to externally validate a deep learning (DL) algorithm by comparing its segmentation of retinal layers and fluid with a gold-standard method for manually adjusting the automatic segmentation of the Heidelberg Spectralis HRA + OCT software Version 6.16.8.0. A total of sixty OCT images of healthy subjects and patients with intermediate and exudative age-related macular degeneration (AMD) were included. A quantitative analysis of the retinal thickness and fluid area was performed, and the discrepancy between these methods was investigated. The results showed a moderate-to-strong correlation between the metrics extracted by both software types, in all the groups, and an overall near-perfect area overlap was observed, except for in the inner segment ellipsoid (ISE) layer. The DL system detected a significant difference in the outer retinal thickness across disease stages and accurately identified fluid in exudative cases. In more diseased eyes, there was significantly more disagreement between these methods. This DL system appears to be a reliable method for accessing important OCT biomarkers in AMD. However, further accuracy testing should be conducted to confirm its validity in real-world settings to ultimately aid ophthalmologists in OCT imaging management and guide timely treatment approaches.

A new intelligent system based deep learning to detect DME and AMD in OCT images

Optical Coherence Tomography (OCT) is widely recognized as the leading modality for assessing ocular retinal diseases, playing a crucial role in diagnosing retinopathy while maintaining a non-invasive modality. The increasing volume of OCT images underscores the growing importance of automating image analysis. Age-related diabetic Macular Degeneration (AMD) and Diabetic Macular Edema (DME) are the most common cause of visual impairment. Early detection and timely intervention for diabetes-related conditions are essential for preventing optical complications and reducing the risk of blindness. This study introduces a novel Computer-Aided Diagnosis (CAD) system based on a Convolutional Neural Network (CNN) model, aiming to identify and classify OCT retinal images into AMD, DME, and Normal classes. Leveraging CNN efficiency, including feature learning and classification, various CNN, including pre-trained VGG16, VGG19, Inception_V3, a custom from scratch model, BCNN (VGG16)2 , BCNN (VGG19)2 , and BCNN (Inception_V3)2 , are developed for the classification of AMD, DME, and Normal OCT images. The proposed approach has been evaluated on two datasets, including a DUKE public dataset and a Tunisian private dataset. The combination of the Inception_V3 model and the extracted feature from the proposed custom CNN achieved the highest accuracy value of 99.53% in the DUKE dataset. The obtained results on DUKE public and Tunisian datasets demonstrate the proposed approach as a significant tool for efficient and automatic retinal OCT image classification.

INTERSESSION REPEATABILITY OF READING PERFORMANCE MEASURES IN PATIENTS WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION

PURPOSE

To assess the intersession repeatability of reading performance measures in patients with previously treated neovascular age-related macular degeneration and good best-corrected visual acuity (≥20/40 Snellen).

METHODS

Ninety-one patients (91 eyes) with a diagnosis of previously treated neovascular age-related macular degeneration and good best-corrected visual acuity (≥20/40 Snellen) were prospectively enrolled. Reading performance metrics were assessed using Radner charts, and these measurements were repeated after 7 days to obtain the intersession repeatability. To test repeatability, we calculated the intraclass correlation coefficient, the 95% coefficient of repeatability, and the coefficient of variation for each reading parameter: 1) reading acuity (RA-LogRAD); 2) maximal reading speed-words per minute; 3) RA score (RA score-LogRAD); and 4) critical print size-LogRAD.

RESULTS

Mean ± standard deviation best-corrected visual acuity was 0.13 ± 0.01 logMAR [range: 0.00-0.30 logMAR]. The intraclass correlation coefficient values indicated a good reliability for all the analyzed metrics (0.901 for RA; 0.859 for max reading speed; 0.906 for RA score; and 0.868 for critical print size). The coefficient of repeatability was 0.2 LogRAD for RA, 63.2 words per minute for max reading speed, 0.2 LogRAD for RA score, and 0.2 LogRAD for critical print size. Coefficient of variation was 5.5% for RA, 8.9% for max reading speed, 5.8% for RA score, and 6.9% for critical print size.

CONCLUSION

Reading performance metrics are characterized by good values of intersession repeatability in patients with neovascular age-related macular degeneration with good best-corrected visual acuity. Our findings may grant the employment of such measures in trials assessing the visual outcome in these patients.

What Enables Child Sexual Abuse in Sport? A Systematic Review

Sporting environments provide opportunities for perpetrators to commit child sexual abuse (CSA). While awareness of CSA in sport and preventative interventions are increasing, CSA in sport still occurs at alarming rates. A systematic review was conducted to identify and synthesize the extant literature on the enabling factors for CSA in sport. The 34 included articles were peer-reviewed and were primary sources; had full-text versions in English; included the individual, situational, environmental, or systemic antecedent factors and characteristics which enable CSA in organized sport (clubs, schools, universities, and representative teams); and focused on abuse in children (0-18 years old), and included retrospective incidents. The enabling factors from across the broader sports system were identified and mapped using a systems thinking-based approach, the Risk Management Framework (RMF) and the associated AcciMap method. The results indicated that enabling factors for CSA in sport were identified at multiple levels of the sporting system hierarchy. The results show that 24.1% (n = 46) of the enabling factors identified in the literature relate to the hierarchical level of the Athlete, teammates, opponents, and fans levels, and 52.9% (n = 101) of the enabling factors relate to the level of Direct supervisors, management, medical, and performance personnel level. However, only 13% (n = 25) of enabling factors to CSA in sport were identified at the combined top four hierarchical levels. Results indicate that the problem of CSA in sport is a systems issue, and future research is required to explore how these factors interact to enable CSA in sport.

Vision-Related Quality of Life among Patients with Different Types of Age-Related Macular Degeneration

BACKGROUND

This study aimed to assess the vision-related quality of life (VRQol) of patients with age-related macular degeneration (AMD) and to evaluate VRQol according to different types of AMD.

METHODS

In this small-scale, single-center, prospective investigation, patients with AMD and subjects without any signs of macular disease were asked to complete the NEI-VFQ-39. A total of 159 subjects were included and grouped according to the type of AMD as follows: 40 patients with dry AMD in both eyes (DD), 40 patients with exudative AMD in one eye (DE), 41 patients with exudative AMD in both eyes (EE), and 38 subjects without any signs of macular disease, as a control group (CG).

RESULTS

The average age of the participants was 76 ± 7 years, and 44% were male. Most participants were retired (22.4%), and 75% of patients were initially diagnosed by their ophthalmologist. All the AMD groups had significantly worse overall VRQol than the CG. For general vision, near vision, mental health, and role difficulties, all the AMD groups had significantly lower scores than the CG. For distance vision, color vision, peripheral vision, driving difficulties, dependency, and social functioning, only patients in the EE and DE groups had significantly worse scores than the CG. The type of retinal fluid in patients with exudative AMD had no effect on overall VRQol; however, we found that the presence of pigment epithelial detachment could be associated with more role difficulties, such as completing work or working long hours.

CONCLUSION

All types of AMD had a negative effect on vision-related quality of life. This effect was significantly more pronounced in patients with exudative AMD in at least one eye. However, the type of retinal fluid in patients with exudative AMD had no influence on their overall vision-related quality of life.

Relationships between Patient-Reported Outcome Measures and Clinical Measures in Naïve Neovascular Age-Related Macular Degeneration Patients Treated with Intravitreal Ranibizumab

Our objective was to evaluate changes in patient-reported outcome measures using the NEI-VFQ 25 questionnaire during a treat and extend regimen in naive neovascular Age-Related Macular Degeneration patients, and its correlation with anatomical and functional data. We conducted a prospective observational study. Patients underwent a treat and extend regimen with intravitreal ranibizumab for neovascular Age-Related Macular Degeneration. Initial response was evaluated at 4th month, and subsequently in every follow-up visit. If a clinical response was achieved, the injection interval was extended in two-week increments, up to a maximum of 12 weeks. Quality of life was assessed using the NEI-VFQ 25 questionnaire at baseline, 4th months, and 12th months. Patients were categorized as good or poor responders based on Best corrected visual acuity, central foveal thickness, intraretinal fluid, or subretinal fluid. Treatment with ranibizumab led to a significant improvement in quality of life, with a mean increase in NEI-VFQ 25 score of 4.27 points in the 12th month. No significant differences in improvement were observed between good and poor responders. Quality of life scores in neovascular Age-Related Macular Degeneration patients improved with intravitreal treatment regardless of the clinical response. The early response following the loading phase could indicate better quality of life after one year of treatment, with Best corrected visual acuity being the clinical parameter with the greatest influence on quality of life.

Single-cell sequencing reveals an important role of SPP1 and microglial activation in age-related macular degeneration

Purpose

To investigate the role of senescence-related cytokines (SRCs) in the pathophysiology of age-related macular degeneration (AMD).

Design

The whole study is based on single-cell and bulk tissue transcriptomic analysis of the human neuroretinas with or without AMD. The transcriptomic data of human neuroretinas was obtained from Gene-Expression Omnibus (GEO) database.

Methods

For single-cell transcriptomic analysis, the gene expression matrix goes through quality control (QC) filtering, being normalized, scaled and integrated for downstream analysis. The further analyses were performed using Seurat R package and CellChat R package. After cell type annotation, the expression of phenotype and functional markers of microglia was investigated and cell-cell communication analysis was performed. For bulk tissue transcriptomic analysis, GSE29801 dataset contains the transcriptomic data of human macular neuroretina (n = 118) from control group and AMD patients. The expression of SPP1 in control and AMD subtypes were compared by Student's t-test. In addition, the AMD macular neuroretina were classified into SPP1-low and SPP1-high groups according to the expression level of SPP1. The differentially expressed genes between these two groups were subsequently identified and the pathway enrichment analysis for these genes was further conducted.

Results

Secreted phosphoprotein 1, as an SRC, was revealed to be highly expressed in microglia of AMD neuroretina and the SPP1-receptor signaling was highly activated in AMD neuroretina. In addition, SPP1 signaling was associated with the pro-inflammatory phenotype and phagocytic state of microglia. SPP1 expression was elevated in macular neuroretina with late dry and wet AMD and the inflammatory pathways were found to be activated in SPP1-high AMD macular neuroretina.

Conclusion

Our findings indicated that SPP1 and microglial activation might play an important role in the pathophysiology of AMD. Therefore, SPP1 might serve as a potential therapeutic target for AMD. More in vitro and in vivo studies are required to confirm the results and the therapeutic effect of SPP1-targeting strategy.

Monocular and Binocular Visual Function Assessments and Activities of Daily Living Performance in Age-Related Macular Degeneration

PURPOSE

To evaluate the relationship between specific monocular and binocular visual function (VF) assessments with binocularly performed activities of daily living task tests (ADLTTs) in patients with age-related macular degeneration (AMD) and healthy controls.

DESIGN

Prospective case-control cohort study.

SUBJECTS

Thirty-six AMD patients and 36 controls.

METHOD

Visual field assessments included monocular and binocular best-corrected visual acuity (BCVA), contrast sensitivity (CS), and monocular microperimetry testing for mean macula sensitivity, mean retina sensitivity (MRS), fixation area, and fixation distance from fovea (FDF). Age-related macular degeneration lesion area and sensitivity were measured on OCT and microperimetry, respectively. Participants performed 4 validated ADLTTs with binocular BCVA: (1) reading; (2) item-search; (3) money-counting; and (4) multi-step drink-making tasks.

MAIN OUTCOME MEASURES

Spearman correlations and multivariate regression analysis, adjusted for age, sex, and potential correlation between the 2 eyes, were used to assess the relationship between monocular and binocular VF assessments, and ADLTT performance in both groups.

RESULTS

Age-related macular degeneration patients had poorer VF (BCVA, CS, mean macula sensitivity, and MRS) compared with healthy controls. Monocular BCVA in both better- and worse-vision eyes was moderately correlated with the binocular reading speed and money-counting tasks in participants with AMD. In AMD, monocular worse eye CS, MRS, AMD lesion area on OCT, and lesion sensitivity on microperimetry showed moderate correlations to various ADLTTs, such as reading, money-counting, and drink-making. Similar findings were found in our AMD cohort on multivariate regression analysis. Fewer significant correlations were observed for the better-vision eye, whereas no correlations were observed for healthy controls between VF parameters and ADLTTs. In contrast, significant associations were observed between binocular BCVA and CS with binocular ADLTTs (reading and item-search tasks) but not in AMD patients.

CONCLUSION

Although monocular BCVA remains the most common measure of VF, CS and microperimetry testing also show significant correlations with ADLTTs performance in AMD patients, and should be considered as complimentary VF-outcome measures in both clinical and research settings. Unlike healthy subjects, AMD patients do not rely on binocular VF for ADLTT function, with the worse-vision eye impacting binocular ADLTT function more than the better-vision eye. Therefore, the worse-vision eye should not be neglected during the management of AMD.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Democratizing Health Care in the Metaverse: How Video Games can Monitor Eye Conditions Using the Vision Performance Index: A Pilot Study

Objective

In a world where digital media is deeply engrained into our everyday lives, there lies an opportunity to leverage interactions with technology for health and wellness. The Vision Performance Index (VPI) leverages natural human-technology interaction to evaluate visual function using visual, cognitive, and motor psychometric data over 5 domains: field of view, accuracy, multitracking, endurance, and detection. The purpose of this study was to describe a novel method of evaluating holistic visual function through video game-derived VPI score data in patients with specific ocular pathology.

Design

Prospective comparative analysis.

Participants

Patients with dry eye, glaucoma, cataract, diabetic retinopathy (DR), age-related macular degeneration, and healthy individuals.

Methods

The Vizzario Inc software development kit was integrated into 2 video game applications, Balloon Pop and Picture Perfect, which allowed for generation of VPI scores. Study participants were instructed to play rounds of each video game, from which a VPI score was compiled.

Main Outcome Measures

The primary outcome was VPI overall score in each comparison group. Vision Performance Index component, subcomponent scores, and psychophysical inputs were also compared.

Results

Vision Performance Index scores were generated from 93 patients with macular degeneration (n = 10), cataract (n = 10), DR (n = 15), dry eye (n = 15), glaucoma (n = 16), and no ocular disease (n = 27). The VPI overall score was not significantly different across comparison groups. The VPI subcomponent "reaction accuracy" score was significantly greater in DR patients (106 ± 13.2) versus controls (96.9 ± 11.5), P = 0.0220. The VPI subcomponent "color detection" score was significantly lower in patients with DR (96.8 ± 2.5; p=0.0217) and glaucoma (98.5 ± 6.3; P = 0.0093) compared with controls (101 ± 11). Psychophysical measures were statistically significantly different from controls: proportion correct (lower in DR, age-related macular degeneration), contrast errors (higher in cataract, DR), and saturation errors (higher in dry eye).

Conclusions

Vision Performance Index scores can be generated from interactions of an ocular disease population with video games. The VPI may offer utility in monitoring select ocular diseases through evaluation of subcomponent and psychophysical input scores; however, future larger-scale studies must evaluate the validity of this tool.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Sialic Acid Mimetic Microglial Sialic Acid-Binding Immunoglobulin-like Lectin Agonism: Potential to Restore Retinal Homeostasis and Regain Visual Function in Age-Related Macular Degeneration

Age-related macular degeneration (AMD), a leading cause of visual loss and dysfunction worldwide, is a disease initiated by genetic polymorphisms that impair the negative regulation of complement. Proteomic investigation points to altered glycosylation and loss of Siglec-mediated glyco-immune checkpoint parainflammatory and inflammatory homeostasis as the main determinant for the vision impairing complications of macular degeneration. The effect of altered glycosylation on microglial maintained retinal para-inflammatory homeostasis and eventual recruitment and polarization of peripheral blood monocyte-derived macrophages (PBMDMs) into the retina can explain the phenotypic variability seen in this clinically heterogenous disease. Restoring glyco-immune checkpoint control with a sialic acid mimetic agonist targeting microglial/macrophage Siglecs to regain retinal para-inflammatory and inflammatory homeostasis is a promising therapeutic that could halt the progression of and improve visual function in all stages of macular degeneration.

Geographic atrophy - Signs, symptoms, and quality of life

Geographic atrophy (GA) is a prevalent cause of vision loss among elderly and is associated with a significant loss of function. We reviewed the current literature to assess the effect of GA on patients' daily lives and well-being. We record and organize the signs, symptoms, and impacts that are important in life with GA. Further, we examined the impact of GA on vision-related quality of life. The main complaint among patients was difficulties regarding daily tasks, especially reading and other near activities. However, a large proportion of patients also reported fear, frustration, and anxiety as salient symptoms with large impact. Many patients do not have adequate information about their condition as well as the prognosis. The most commonly used measure of patient-reported outcome measure (PROM) is the National Eye Institute Visual Function Questionnaire (VFQ), that reflects the severity of impact on 12 subscales, from where near activities, general vision, mental health, and role difficulties had the lowest scores. Longitudinal studies of GA and the impact of low-vision rehabilitation efforts on health-related quality of life are sparse but suggest a significant improvement on several items. PROM is included in clinical trials, and so far, no drug has shown to improve the functional outcome in terms of PROM.

Prevalence and secular trends of four causes of blindness and visual impairment in Iran (1990-2019): a comparative study based on the Global Burden of Disease project's data

PURPOSE

The purpose of this study was to investigate the prevalence of cataracts, refractive disorders, age-related macular disease (AMD), and glaucoma, as well as their trends from 1990 to 2019 in Iran, in comparison with high-middle socio-demographic index (HMSDI) countries and the world, using the Global Burden of Disease (GBD) 2019 study.

METHODS

The GBD study provided data on the prevalence of blindness and visual impairment (VI), as well as four of their causes including cataracts, refractive disorders, age-related macular disease (AMD), and glaucoma. Using Joinpoint analysis, the annual percent change (APC) was calculated to assess the trend of change in prevalence in each category of diseases from 1990 to 2019, stratified by sex and age, for Iran, HMSDI countries, and the world.

RESULTS

In 2019, refractive errors and cataracts were the most common causes of blindness and VI for both genders in Iran, HMSDI countries and the world. Iran had a higher age-standardized prevalence in all four categories of ophthalmologic disorders compared to HMSDI countries and the world for both genders in 2019. Additionally, the age-specific prevalence of all four disorders in 2019 was higher in Iran compared to HMSDI countries. However, in terms of trends of prevalence from 1990 to 2019, the rate of reduction for the four ophthalmologic disorders in Iran was higher than in HMSDI and the world for both males and females. Furthermore, Iran had a greater percentage of reduction in prevalence for all age groups in all four disorders compared to HMSDI countries.

CONCLUSION

The prevalence of cataracts, refractive errors, AMD, and glaucoma in Iran was higher compared to HMSDI countries in 2019 for both sexes and all age groups, but the trends of prevalence for all four disorders from 1990 to 2019 in Iran had a higher slope of reduction compared to HMSDI countries for all ages and sexes.

"I'm like something out of star wars": a qualitative investigation of the views of people with age-related macular degeneration regarding wearable electronic vision enhancement systems

PURPOSE

This study explores the initial views of people with age-related macular degeneration towards wearable electronic vision enhancement systems.

METHODS

Ten adults with age-related macular degeneration participated in semi-structured interviews, which were analysed using reflexive thematic analysis.

RESULTS

Four themes were identified. Firstly, participants spoke of the wide-ranging impact of sight loss and how current helpful coping strategies still had significant limitations, affecting their desire to seek new solutions. The second theme showed that "other people" offered welcomed support with existing electronic coping solutions and are needed to provide suitable advice and training. However, "other people" limited the acceptability of using new solutions in public places. The third theme captured participants' desire for a wearable aid providing image magnification and enhancement over a range of distances. The final theme covered the reality of some current wearable technology, perceived as heavy, enclosing, or strange in appearance. Appearance caused some to lose interest in use, although others reframed the devices' desired usefulness to solo and sedentary activities.

CONCLUSION

This population are interested in the potential benefits of wearable electronic vision enhancement systems. More work is needed to understand the suitability of current solutions due to participant concerns about training, appearance and performance.

Comparative analysis of the quality of life among different retinal diseases

PURPOSE

To assess the impact on the quality of life (QoL) among different retinal diseases such as diabetic macular edema (DME), retinal vein occlusion (RVO), pathologic myopia (PM), neovascular age-related macular degeneration (nAMD) and central serous chorioretinopathy (CSC).

METHODS

A cross-sectional study was carried out in 241 patients, affected by DME (n=44), RVO (n=41), PM (n=34) and nAMD (n=85) receiving intravitreal injections due to the presence of macular edema or choroidal neovascularization. The CSC patients included (n=37) were candidates for laser treatment. The patients included completed the National Eye Visual Functioning Questioning-25 (NEI VFQ-25). Best eye visual acuity (BEVA) was recorded using the Early Treatment Diabetic Retinopathy Study (ETDRS) scale.

RESULTS

There were significant differences between subgroups for all the domains, except for the general vision in which all scores among diseases ranged from 40.7 to 45.2 out of 100 (P=.436), despite the difference in BEVA (CSC: 86.3±11.9; RVO: 78.5±15.5, DME: 73.3±15.2, nAMD: 72.9±12.6 and PM: 68.5±18.1 letters respectively; P<.001). The lowest VFQ-25 total score was observed in the PM patients (52.1±20.9), followed by nAMD (55.3±20.8), RVO (65.0±22.3), DME (68.6±21.0) and CSC (70.9±16.2). The DME group reported the worst score for general health (38.9±21.4). Mental health and role difficulties were lowest for PM (48.2±28.8 and 48.2±31.9, P<.007).

CONCLUSIONS

This study reveals the differences in the QoL among DME, RVO, nAMD, PM and CSC, describing the different repercussions that they can suffer, observing a higher impact in PM and nAMD.

Optimizing Visual Outcomes in Patients With Neovascular Age-Related Macular Degeneration: the Potential Value of Sustained Anti-VEGF Therapy

Neovascular age-related macular degeneration (nAMD) leads to irreversible central vision loss if untreated. Frequent administration of anti-vascular endothelial growth factor (anti-VEGF) injections inhibits disease activity with excellent functional and morphological benefits. However, these injections pose a heavy therapeutic burden, and treatment discontinuation is common. Although current anti-VEGF treatment paradigms, such as treat-and-extend, mitigate treatment burden while still leading to acceptable vision outcomes, they fail to sustain initial vision gains for many. Novel longer-acting anti-VEGF therapies may reduce the overall burden on nAMD patients. Gene therapy might offer a paradigm shift by providing continuous expression of anti-VEGF, potentially decreasing treatment requirements and improving long-term vision outcomes. [Ophthalmic Surg Lasers Imaging Retina 2023;54:654-659.].

Low vision devices for age-related macular degeneration: a systematic review

PURPOSE

Age-related macular degeneration (AMD) is a degenerative condition impacting central vision. Evaluating the effectiveness of low vision devices provides empirical evidence on how devices can rehabilitate and overcome deficits caused by AMD. This evidence could help to facilitate discussion on necessary future improvements to vision enhancement technology.

METHODS

A systematic review of the literature was conducted on low vision device use in AMD populations. Relevant peer-reviewed research articles from six databases were screened.

RESULTS

The findings of thirty-five studies revealed a significant positive impact of low vision devices leading to improvements in visual acuity, reading performance, facial recognition, and more. While the studies were found to have moderate risks of bias, a GRADE assessment of the evidence suggested the certainty of the evidence was low-moderate.

DISCUSSION

Simple hand-held low vision devices (e.g., magnifiers) appear to currently have greater preferential support than newer visual enhancement technology (e.g., head mounted devices). Financial, comfort or usability reasons may influence preferences more than performance-based findings. However, there is a lack of studies examining newer technologies in AMD populations, which future research should address. Moreover, given the presence of bias across the studies and limited controlled experiments, confidence in the results may be low.

CONCLUSIONS

Most studies indicated that low vision devices have positive impacts on reading and visual performance. But, even though they are reported to be a valuable asset to AMD populations, more rigorous research is required to draw conclusive evidence. IMPLICATIONS FOR REHABILITATIONLow vision devices can improve patient outcomes (e.g., vision, reading ability) for age-related macular degeneration populations.A multidisciplinary combination of low vision devices and rehabilitative services (i.e., eccentric viewing training, counselling, education) may enhance quality of life.

Sleep duration and age-related macular degeneration: a cross-sectional and Mendelian randomization study

Purpose

To investigate the association between sleep duration and age-related macular degeneration (AMD).

Design

Cross-sectional study, bidirectional two-sample Mendelian randomization (MR). For cross-sectional analysis, we used survey data of 5,481 participants aged ≥40 years from the 2005 to 2008 National Health and Nutrition Examination Survey (NHANES). For MR analysis, we used sleep- and AMD-associated genome-wide association studies (GWAS) data involving large populations.

Methods

The association between sleep duration and AMD was assessed using logistic regression models. For MR analysis, the primary approach for MR analysis was the inverse-variance weighted (IVW) method.

Results

In cross-sectional analysis, after adjusting for multiple covariates, short sleep duration (SSD) was found to be associated with increased risk of early AMD [odds ratio (OR) = 1.364, P = 0.036). MR analysis supported the results of cross-sectional analysis: SSD increases the risk of early AMD (β = 0.102, IVW-P = 0.003).

Conclusion

Our findings provide the evidence supporting the association between sleep deficiency and higher risk of AMD. Further studies are required to confirm our findings and elucidate the mechanisms underlying this association.

Pain related to intravitreal injections for age-related macular degeneration: a qualitative study of the perspectives of patients and practitioners

OBJECTIVES

Ocular pain is a commonly reported finding in the intravitreal injection procedure, but post-injection experiences and patient adherence to treatment remain underexplored. We therefore aimed to identify key variations in the intravitreal injection procedure that may influence pain, and to gain insights into the post-injection experience and treatment adherence from the perspective of patients and practitioners.

DESIGN

Qualitative semistructured interview study using reflexive thematic analysis of transcripts.

SETTING

Hospital Eye Clinic in Wales, UK. Interviews were conducted between May and September 2019.

PARTICIPANTS

Purposive sample of patients aged ≥50 years with neovascular age-related macular degeneration and no other retinal pathology who had received at least six intravitreal injections, and practitioners including ophthalmologists, registered nurses and optometrists who performed intravitreal injections at the research site.

RESULTS

Data saturation was reached with 21 interviews: 14 patients and 7 practitioners. Three main themes were identified from the analysis: fear of losing eyesight and treatment anxiety influence patient adherence to treatment, variability in pain experience during treatment, and post-injection experience and impact on patient recovery. To reassure patients feeling apprehensive about the injections, practitioners promoted safety and trust, and used techniques to manage anxiety. Key variations that may influence pain identified were application of antiseptic or anaesthetic, injecting methods and communication. During injection, patients reported a dull-aching and sharp pain, contrary to practitioners' perspective of feeling a 'pressure'. Patients described prolonged soreness and irritation of up to 36 hours post-injection affecting their sleep and recovery.

CONCLUSION

Establishing rapport supported patients to recognise the necessity of ongoing treatment to prevent sight loss; however, inadequate pain management led to undesirable outcomes. Practitioners should use pain assessment tools during and immediately after injection and provide ongoing consistent information to help patients manage pain at home.

Geographic Atrophy after Reabsorption of Pigment Epithelial Detachment (GARPED) study

BACKGROUND

To describe the occurrence, rate of geographic atrophy (GA) expansion, and changes in visual acuity (VA) after reabsorption of subfoveal pigment epithelial detachments (PED).

METHODS

Included patients had reabsorption of a PED followed by GA. Patients underwent clinical examination with SD-OCT. Images were classified by size with grading occurring post reabsorption. VA was recorded pre-reabsorption, post-reabsorption, and over time.

RESULTS

The average age of the cohort, consisting of 22 eyes from 19 participants, was 86.9 years at reabsorption. Prior to reabsorption, the VA was 20/80 and then declined to 20/200 (p = 0.001) with an average follow-up time of 30.2 months. There was no significant VA change after the initial loss with reabsorption. The average initial lesion size of GA was 0.987 mm² with an average growth rate of 0.274 mm/year.

CONCLUSIONS

This study longitudinally examined GA growth rate in patients with reabsorbed PEDs. These patients started with a drusenoid or serous PED, had a dramatic reduction in vision and GA that occurred in place of the PED. These GA lesions have a slower growth rate and a smaller area of onset compared to rates previously reported in the literature. They do not show significant VA change after reabsorption. As we have entered the era of GA therapy, these patients may not benefit from current treatments.

Age-related macular degeneration

Age-related macular degeneration is an increasingly important public health issue due to ageing populations and increased longevity. Age-related macular degeneration affects individuals older than 55 years and threatens high-acuity central vision required for important tasks such as reading, driving, and recognising faces. Advances in retinal imaging have identified biomarkers of progression to late age-related macular degeneration. New treatments for neovascular age-related macular degeneration offer potentially longer-lasting effects, and progress is being made towards a treatment for atrophic late age-related macular degeneration. An effective intervention to slow progression in the earlier stages of disease, or to prevent late age-related macular degeneration development remains elusive, and our understanding of underlying mechanistic pathways continues to evolve.

Impact of COVID-19 Confinement on Quality of Life of Patients with Age-Related Macular Degeneration: A Two-Wave Panel Study

Age-related macular degeneration (AMD) is the leading cause of blindness in developed countries. Intravitreal injections of antiangiogenic agents (anti-VEGF) can stop vision loss in the neovascular form of the disease (nAMD). The aim of this study was to assess the general health-related quality of life (HRQoL) in a cohort of patients with nAMD treated with intravitreal anti-VEGF injections and to detesrmine to what extent their HRQoL was affected by COVID-19. This was an observational, analytical, and longitudinal study performed with a two-wave panel survey. Clinical outcomes, HRQoL, and tangible support were evaluated. In the final survey, changes in living conditions and medical visits due to the COVID-19 pandemic were also examined. Of the 102 patients initially interviewed in the before-COVID survey, 24 were lost after 30 months of follow-up. In the initial assessment, the mean health index was 0.73 ± 0.2. The EQ VAS score worsened at the final survey (p = 0.048). Patients needing treatment in both eyes (p = 0.007) and with lower levels of bilateral visual acuity (p = 0.018) reported an increase in social support at the final survey. In conclusion, patients perceived a worsening in HRQoL after confinement. However, patients enjoyed good social support that improved in the after-COVID survey.

Low vision home therapy service by occupational therapists: The effectiveness of the Seniors’ Eye Rehabilitation programme, a pilot study

Introduction:

This study aims to explore the effectiveness of the Seniors’ Eye Rehabilitation (SEER) pilot programme, a visual rehabilitation home therapy by specialised low vision occupational therapists (LVOT).

Method:

This was an interventional, longitudinal cohort study. Participants were recruited from Singapore National Eye Centre Low Vision Clinic. The occupational therapy interventions include activities of daily living retraining, activities/home modifications, functional/community mobility training and patient/family education. Each participant set two individualised goals (Priority Goal 1 and Priority Goal 2). The Wilcoxon signed-rank test was used to compare baseline and 6-month follow-up scores for Australian Therapy Outcome Measures for Occupational Therapy (AusTOMs-OT) and the Goal Attainment Scale (GAS) ( p < 0.05).

Results:

Forty-one participants (mean age: 67, 48.8% male) completed SEER. There was statistically significant reduction in activity limitations (1 median point change (MPC), Z = −4.21, p < 0.01), participation restrictions (1 MPC, Z = −3.951, p < 0.01) and improved well-being (0.5 MPC, Z = −3.668, p < 0.01) for Priority Goal 1 using AUSTOM-OT. With GAS, there was a statistically significant improvement in Priority Goal 1 (1 MPC, Z = −3.886, p < 0.01).

Conclusion:

The SEER programme was found to be effective in improving all domains of the AusTOMs-OT and GAS for Priority Goal 1. This provides evidence that visual rehabilitation home therapy by specialised LVOT is beneficial to older adults with visual impairment.

The effects of age and central field loss on maintaining balance control when stepping up to a new level under time-pressure

Objective

To investigate the effects of age and central field loss on the landing mechanics and balance control when stepping up to a new level under time-pressure.

Methods

Eight older individuals with age-related macular degeneration (AMD), eight visually normal older and eight visually normal younger individuals negotiated a floor-based obstacle followed by a 'step-up to a new level' task. The task was performed under (1) no-pressure; (2) time-pressure: an intermittent tone was played that increased in frequency and participants had to complete the task before the tone ceased. Landing mechanics and balance control for the step-up task was assessed with a floor-mounted force plate on the step.

Results

Increased ground reaction forces and loading rates were observed under time-pressure for young and older visual normals but not for AMD participants. Across conditions, loading rates and ground reaction forces were higher in young normals compared to older normals and AMD participants. Young visual normals also demonstrated 35-39% shorter double support times prior to and during the step-up compared to older normals and AMD participants. All groups shortened their double support times (31-40%) and single support times (7-9%) in the time-pressure compared to no-pressure condition. Regarding balance control, the centre-of-pressure displacement and velocity in the anterior-poster direction were increased under time-pressure for young and older visual normals but not for AMD participants. The centre-of-pressure displacement and velocity in the medial-lateral direction were decreased for the AMD participants under time-pressure but not for young and older visual normals.

Conclusions

Despite walking faster, AMD participants did not adapt their landing mechanics under time-pressure (i.e., they remained more cautious), whilst older and young adults with normal vision demonstrated more forceful landing mechanics with the young being most forceful. A more controlled landing might be a safety strategy to maintain balance control during the step-up, especially in time-pressure conditions when balance control in the anterior-posterior direction is more challenged.

Using augmented reality to cue obstacles for people with low vision

Detecting and avoiding obstacles while navigating can pose a challenge for people with low vision, but augmented reality (AR) has the potential to assist by enhancing obstacle visibility. Perceptual and user experience research is needed to understand how to craft effective AR visuals for this purpose. We developed a prototype AR application capable of displaying multiple kinds of visual cues for obstacles on an optical see-through head-mounted display. We assessed the usability of these cues via a study in which participants with low vision navigated an obstacle course. The results suggest that 3D world-locked AR cues were superior to directional heads-up cues for most participants during this activity.

Ocular streptococcal infections: A clinical and microbiological review

Streptococcus is a diverse bacterial genus that is part of the ocular surface microbiome implicated in conjunctivitis, keratitis, endophthalmitis, dacryocystitis, and orbital cellulitis which can lead to decreased visual acuity and require surgical intervention. The pathophysiology of S. pneumoniae is well established and the role of the polysaccharide capsule, pneumolysin, neuraminidases, and zinc metalloproteinases in ocular infections described. Additionally, key virulence factors of the viridans group streptococci such as cytolysins and proteases have been outlined, but there is a paucity of research on the remaining streptococcus species. These virulence factors tend to result in aggressive disease. Clinically, S. pneumoniae is implicated in 2.7-41.2% of bacterial conjunctivitis cases, more predominant in the pediatric population, and is implicated in 1.8-10.7% of bacterial keratitis isolates. Streptococcus bacteria are significantly implicated in acute postoperative, post-intravitreal, and bleb-associated endophthalmitis, responsible for 10.3-37.5, 29.4, and 57.1% of cases, respectively. Group A and B streptococcus endogenous endophthalmitis is rare, but has a very poor prognosis. Inappropriate prescription of antibiotics in cases of non-bacterial aetiology has contributed to increasing resistance, and a clinical index is needed to more accurately monitor this. Furthermore, there is an increasing need for prospective, surveillance studies of antimicrobial resistance in ocular pathogens, as well as point-of-care testing using molecular techniques.

Consistency of preferred retinal locus across tasks and participants trained with a simulated scotoma

After loss of central vision following retinal pathologies such as macular degeneration (MD), patients often adopt compensatory strategies including developing a "preferred retinal locus" (PRL) to replace the fovea in tasks involving fixation. A key question is whether patients develop multi-purpose PRLs or whether their oculomotor strategies adapt to the demands of the task. While most MD patients develop a PRL, clinical evidence suggests that patients may develop multiple PRLs and switch between them according to the task at hand. To understand this, we examined a model of central vision loss in normally seeing individuals and tested whether they used the same or different PRLs across tasks after training. Nineteen participants trained for 10 sessions on contrast detection while in conditions of gaze-contingent, simulated central vision loss. Before and after training, peripheral looking strategies were evaluated during tasks measuring visual acuity, reading abilities and visual search. To quantify strategies in these disparate, naturalistic tasks, we measured and compared the amount of task-relevant information at each of 8 equally spaced, peripheral locations, while participants performed the tasks. Results showed that some participants used consistent viewing strategies across tasks whereas other participants' strategies differed depending on task. This novel method allows quantification of peripheral vision use even in relatively ecological tasks. These results represent one of the first examinations of peripheral viewing strategies across tasks in simulated vision loss. Results suggest that individual differences in peripheral looking strategies following simulated central vision loss may model those developed in pathological vision loss.

Efficacy and Patients' Satisfaction with the ORCAM MyEye Device Among Visually Impaired People: A Multicenter Study

To evaluate usability of and satisfaction with OrCam MyEye, a finger-size wearable assistive technology device for visually impaired during real-world tasks. This prospective multicenter study was conducted on visually impaired people recruited from 5 vision rehabilitation centers. Patients performed real-world tasks such as near and distance reading, money handling, colour identification and face recognition in 2 different scenarios: without using any low vision aid and with OrCam. System Usability Scale (SUS), Patient's Global Impression of Change (PGIC), the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST 2.0) and the Psychosocial Impact of Assistive Devices Scale (PIADS) were administered after the use of the OrCam device. Among the 100 participants, use of OrCam MyEye device improved many daily-living tasks (F = 1.67, P < .05), and in particular reading and face recognition. Multivariate logistic regression showed that age and visual field defect explained 89% of the variation in efficacy of the device. Nearly half (45%) of the participants indicated a positive rating with the SUS. The PGIC rates showed a minimal improvement with a mean score of 4.2 (SD:1.8). The most highlighted parameter with the QUEST 2.0 test was "ease of use" in 58% (48 subjects). The PIADS indicator showed that the device positively impacted on the daily-living tasks of users (r2 = 0.72, P < .05). Regression modelling demonstrated a good relation between the questionnaires scores and demographic, disease and visual factors (P < .05). OrCam MyEye allowed visually impaired people to read, handle money and face recognition independently. This device may offer to these subjects to be independent.

The intraocular implant and visual rehabilitation improve the quality of life of elderly patients with geographic atrophy secondary to age-related macular degeneration

INTRODUCTION

The objective of this prospective study was to evaluate the effects of intraocular macular lens implantation and visual rehabilitation on the quality of life of patients with geographic atrophy (GA) secondary to age-related macular degeneration (AMD).

METHODS

Patients with bilaterally decreased near vision (not better than 0.3 logMAR with the best correction), pseudophakia, were included in the project. The Scharioth macula lens (SML) was implanted into the patients' better-seeing eye. Intensive visual rehabilitation of the ability to perform nearby activities was performed for 20 consecutive postoperative days. All subjects were examined before and after SML implantation ophthalmologically. The National Eye Institute 25-Item Visual Function Questionnaire (NEI VFQ-25) was administered before and 6 months after surgery.

RESULTS

Twenty eligible patients with mean age 81 years (63 to 92 years) were included in the project: 7 males and 13 females. Nineteen of them completed the 6-month follow-up. Near uncorrected visual acuity was 1.321 ± 0.208 logMAR before SML implantation and improved to 0.547 ± 0.210 logMAR after 6 months (dz =  - 2.846, p < 0.001, BF₁₀ = 3.29E + 07). In the composite score of the NEI VFQ-25, there was an improvement in the general score and the specific domains related to the implantation. Participants reported fewer difficulties in performing near activities (dz = 0.91, p = 0.001, BF₁₀ = 39.718) and upturns in mental health symptoms related to vision (dz = 0.62, p = .014, BF₁₀ = 3.937).

CONCLUSION

SML implantation, followed by appropriate rehabilitation, improved near vision and increased the quality of life of visually handicapped patients with AMD in our project.

Empowerment-Based Physical Activity Intervention for People with Advanced Dry Age-Related Macular Degeneration: Mixed-Methods Protocol

Age-related macular degeneration (AMD) is the most common cause of incurable visual impairment and impacts daily life. These impacts include loss of social activities, decreased functional independence, and reduced physical activity. This protocol aims to describe a prospective, mixed-methodology for studying a population with AMD before, during, and after an empowerment-based physical activity intervention (EPI). A study framework was also developed for EPI. The intervention will include 20 older individuals (age 65+ years) with AMD recruited in Sweden. The intervention period is six months and comprises adapted physical activity and social activities in a group twice a week and individual health coaching on three occasions. The quantitative pre-test and three follow-ups include physical functional tests, an accelerometer that monitors physical activity continuously for one week, and questionnaires. Individual and focus-group interviews and ethnographic observations will explore the experience of living with AMD and what it means to participate in the EPI for individuals with AMD. The chosen methodology offers a structured way for researchers to explore the experiences and factors that may provide insights into the potential of creative supervised, adapted physical activity in groups, health coaching, and socialising that are significant to enable well-being among older individuals with AMD.

Impact of neovascular age-related macular degeneration on eye-movement control during scene viewing: Viewing biases and guidance by visual salience

Human vision requires us to analyze the visual periphery to decide where to fixate next. In the present study, we investigated this process in people with age-related macular degeneration (AMD). In particular, we examined viewing biases and the extent to which visual salience guides fixation selection during free-viewing of naturalistic scenes. We used an approach combining generalized linear mixed modeling (GLMM) with a-priori scene parcellation. This method allows one to investigate group differences in terms of scene coverage and observers' well-known tendency to look at the center of scene images. Moreover, it allows for testing whether image salience influences fixation probability above and beyond what can be accounted for by the central bias. Compared with age-matched normally sighted control subjects (and young subjects), AMD patients' viewing behavior was less exploratory, with a stronger central fixation bias. All three subject groups showed a salience effect on fixation selection-higher-salience scene patches were more likely to be fixated. Importantly, the salience effect for the AMD group was of similar size as the salience effect for the control group, suggesting that guidance by visual salience was still intact. The variances for by-subject random effects in the GLMM indicated substantial individual differences. A separate model exclusively considered the AMD data and included fixation stability as a covariate, with the results suggesting that reduced fixation stability was associated with a reduced impact of visual salience on fixation selection.

Topical Review: Impact of Central Vision Loss on Navigation and Obstacle Avoidance while Walking

SIGNIFICANCE

Individuals with central vision loss are at higher risk of injury when walking and thus may limit trips outside the home. Understanding the mobility challenges associated with central vision loss (CVL) can lead to more effective interventions.A systematic literature review focusing on mobility in CVL was conducted. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method, 2424 articles were identified in 4 databases (PsycINFO, APA PsycArticles, PubMed, and Web of Science). To be included within this review, the study methodology needed to be related to the three components of walking: (1) navigation, defined as the ability to reach a target destination; (2) obstacle avoidance, defined as the ability to avoid collisions with obstacles located at various heights and directions; and (3) street crossing, defined as the ability to both navigate a path and avoid collisions in a traffic environment. The methodology also needed to be empirical. Case studies, unstructured observational studies, studies based on self-report, research proposals, and existing systematic reviews were excluded. Titles, abstracts, and full text of identified articles were screened, yielding 26 articles included in the review. Results showed that, in many tasks, individuals with CVL can accomplish a level of performance comparable with individuals with normal vision. Differences between normal and impaired vision were due to either age or how the groups completed the task. For example, individuals with CVL could cross a street successfully but did so less safely (i.e., smaller safety margins) than individuals with normal vision. To identify new interventions for CVL, future research should focus on the differences in the mechanisms underlying mobility between individuals with normal and impaired vision rather than solely on performance differences.

Assessment of the Classification of Age-Related Macular Degeneration Severity from the Northern Ireland Sensory Ageing Study Using a Measure of Dark Adaptation

Purpose

To assess the differences in rod-mediated dark adaptation (RMDA) between different grades of age-related macular degeneration (AMD) severity using an OCT-based criterion compared with those of AMD severity using the Beckman color fundus photography (CFP)-based classification and to assess the association between the presence of subretinal drusenoid deposits (SDDs) and RMDA at different grades of AMD severity using an OCT-based classification.

Design

Cross-sectional study.

Participants

Participants from the Northern Ireland Sensory Ageing study (Queen's University Belfast).

Methods

Complete RMDA (rod-intercept time [RIT]) data, CFP, and spectral-domain OCT images were extracted. Participants were stratified into 4 Beckman groups (omitting late-stage AMD) and 3 OCT-based groups. The presence and stage of SDDs were identified using OCT.

Main Outcome Measures

Rod-intercept time data (age-corrected).

Results

Data from 459 participants (median [interquartile range] age, 65 [59-71] years) were stratified by both the classifications. Subretinal drusenoid deposits were detected in 109 eyes. The median (interquartile range) RMDA for the Beckman classification (Beckman 0-3, with 3 being intermediate age-related macular degeneration [iAMD]) groups was 6.0 (4.5-8.7), 6.6 (4.7-10.5), 5.7 (4.4-7.4), and 13.2 (6-21.1) minutes, respectively. OCT classifications OCT0-OCT2 yielded different median (interquartile range) values: 5.8 (4.5-8.5), 8.4 (5.2-13.3), and 11.1 (5.3-20.1) minutes, respectively. After correcting for age, eyes in Beckman 3 (iAMD) had statistically significantly worse RMDA than eyes in the other Beckman groups (P ≤ 0.005 for all), with no statistically significant differences between the other Beckman groups. Similarly, after age correction, eyes in OCT2 had worse RMDA than eyes in OCT0 (P ≤ 0.001) and OCT1 (P < 0.01); however, there was no statistically significant difference between eyes in OCT0 and eyes in OCT1 (P = 0.195). The presence of SDDs was associated with worse RMDA in OCT2 (P < 0.01) but not in OCT1 (P = 0.285).

Conclusions

Eyes with a structural definition of iAMD have delayed RMDA, regardless of whether a CFP- or OCT-based criterion is used. In this study, after correcting for age, the RMDA did not differ between groups of eyes defined to have early AMD or normal aging, regardless of the classification. The presence of SDDs has some effect on RMDA at different grades of AMD severity.

Exploring challenges to nutrition intervention adherence using COM-B model among patients with wet age-related macular degeneration: a qualitative study

OBJECTIVES

To explore challenges to nutrition intervention adherence using the Capability, Opportunity and Motivation-Behaviour (COM-B) model among wet age-related macular degeneration (AMD) patients. These factors should be considered in the development of potential support and intervention programmes to address these problems.

DESIGN

A qualitative study was conducted with one-to-one and face-to-face interviews with wet AMD patients using a semi-structured question guide. Data were analysed based on COM-B model: capability (physical and psychological), opportunity (physical and social) and motivation (reflective and automatic).

SETTING

Southwest Hospital of Chongqing Province in China.

PARTICIPANTS

A convenient and purposive sample of 24 wet AMD patients were recruited.

RESULTS

The themes and subthemes were identified: psychological capability: (1) insufficient knowledge of nutrition; (2) misconceptions about the disease and treatment; (3) knowledge conflict; physical capability: (1) physical restriction; (2) limited access to nutrition knowledge; physical opportunity: (1) communication between providers and patients; (2) health insurance and extra charges; (3) food environment; social opportunity: (1) stigma of disease; (2) family influence; reflective motivation: (1) self-efficacy; (2) attitude; (3) outcome expectancies; (4) lack of professional support; automatic motivation: (1) difficulties in changing eating habits; (2) mindset.

CONCLUSION

Medical staff should pay much attention to the process of patients' nutrition intervention. In addition, it is also necessary to develop professional and internet-based intervention to modify the dietary behaviour and improve the management skills of the patients.

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

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

Age-related macular degeneration and myeloproliferative neoplasms - A common pathway

DANSK RESUMÉ (DANISH SUMMARY): Aldersrelateret makuladegeneration (AMD) er den hyppigste årsag til uopretteligt synstab og blindhed i højindkomstlande. Det er en progredierende nethindesygdom som gradvist fører til ødelaeggelse af de celler som er ansvarlige for vores centralsyn. De tidlige stadier er ofte asymptomatiske, imens senstadie AMD, som opdeles i to former, neovaskulaer AMD (nAMD) og geografisk atrofi (GA), begge udviser gradvist synstab, dog generelt med forskellig hastighed. Tidlig AMD er karakteriseret ved tilstedevaerelsen af druser og pigmentforandringer i nethinden mens nAMD og GA udviser henholdsvis karnydannelse i og atrofi af nethinden. AEtiologien er multifaktoriel og udover alder omfatter patogenesen miljø- og genetiske risikofaktorer. Forskning har specielt fokuseret på lokale forandringer i øjet hvor man har fundet at inflammation spiller en betydelig rolle for udviklingen af sygdommen, men flere studier tyder også på at systemiske forandringer og specielt systemisk inflammation spiller en vaesentlig rolle i patogenesen. De Philadelphia-negative myeloproliferative neoplasier (MPNs) er en gruppe af haematologiske kraeftsygdomme med en erhvervet genetisk defekt i den tidlige pluripotente stamcelle som medfører en overproduktion af en eller flere af blodets modne celler. Sygdommene er fundet at udvikle sig i et biologisk kontinuum fra tidligt cancerstadie, essentiel trombocytose (ET) over polycytaemi vera (PV) og endelig til det sene myelofibrose stadie (PMF). Symptomer hos disse patienter skyldes isaer den aendrede sammensaetning af blodet, hyperviskositet, kompromitteret mikrocirkulation og nedsat vaevsgennemblødning. Den øgede morbiditet og mortalitet beror i høj grad på tromboembolier, blødninger og leukemisk transformation. En raekke mutationer som driver MPN sygdommene er identificeret, bl.a. JAK2V617F-mutationen som medfører en deregulering JAK/STAT signalvejen, der bl.a. har betydning for cellers vaekst og overlevelse. Et tidligere stort registerstudie har vist at patienter med MPNs har en øget risiko for neovaskulaer AMD og et pilotstudie har vist øget forekomst af intermediaer AMD. Dette ønsker vi at undersøge naermere i et større studie i dette Ph.d.- projekt. Flere studier har også vist at kronisk inflammation spiller en vigtig rolle for både initiering og udvikling af den maligne celleklon hos MPNs og herfra er en "Human Inflammationsmodel" blevet udviklet. Siden er MPN sygdommene blevet anvendt som "model sygdomme" for en tilsvarende inflammationsmodel for udvikling af Alzheimers sygdom. I dette Ph.d.-projekt vil vi tilsvarende forsøge at undersøge systemisk inflammation i forhold til forekomst af druser. Det vil vi gøre ved at sammenligne systemiske immunologiske markører som tidligere er undersøgt hos patienter med AMD og sammenligne med MPN. Specielt er vi interesseret i systemiske immunologiske forskelle på patienter med MPN og druser (MPNd) og MPN med normale nethinder (MPNn). Denne afhandling består af to overordnede studier. I Studie I, undersøgte vi forekomsten af retinale forandringer associeret med AMD hos 200 patienter med MPN (artikel I). Studie II, omhandlede immunologiske ligheder ved AMD og MPN, og var opdelt i yderligere tre delstudier hvor vi undersøgte hhv. systemiske markører for inflammation, aldring og angiogenese (artikel II, III og IV). Vi undersøgte markørerne i fire typer af patienter: nAMD, intermediaer AMD (iAMD), MPNd og MPNn. Undersøgelsen af forskelle mellem MPNd og MPNn, vil gøre det muligt at identificere forandringer i immunsystemet som kunne vaere relevante for AMD-patogenesen. Vi vil endvidere sammenholde resultaterne for patienter med MPN med patienter som har iAMD og nAMD. I studie I (Artikel I) fandt vi at patienter med MPN har en signifikant højere praevalens af store druser og AMD tidligere i livet sammenlignet med estimater fra tre store befolkningsundersøgelser. Vi fandt også at forekomst af druser var associeret med højere neutrofil-lymfocyt ratio, hvilket indikerer et højere niveau af kronisk inflammation i patienterne med druser sammenlignet med dem uden druser. I studie II (Artikel II, III og IV) fandt vi flere immunologiske forskelle mellem patienter med MPNd og MPNn. Da vi undersøgte markører for inflammation, fandt vi en højere grad af systemisk inflammation i MPNd end MPNn. Dette blev vist ved en højere inflammationsscore (udregnet på baggrund af niveauer af pro-inflammatoriske markører), en højere neutrofil-lymfocyt ratio, samt indikationer på et dereguleret komplementsystem. Ved undersøgelse af aldringsmarkører fandt vi tegn på accelereret immunaldring hos MPNd i forhold til MPNn, hvilket kommer til udtryk ved en større procentdel af "effector memory T celler". Endelig fandt vi en vaesentlig lavere ekspression af CXCR3 på T celler og monocytter hos patienter med nAMD sammenlignet med iAMD, MPNd og MPNn. Dette er i overensstemmelse med tidligere studier hvor CXCR3 ekspression er fundet lavere end hos raske kontroller. Derudover fandt vi en faldende CXCR3 ekspression på monocytter over det biologiske MPN-kontinuum. Disse studier indikerer en involvering af CXCR3 i både nAMD og PMF, begge sygdomsstadier som er karakteriseret ved angiogenese og fibrose. Ud fra resultaterne af denne afhandling kan vi konkludere at forekomsten af druser og AMD hos MPN er øget i forhold til baggrundsbefolkningen. Endvidere viser vores resultater at systemisk inflammation muligvis spiller en vaesentlig større rolle i udviklingen af AMD end tidligere antaget. Vi foreslår derfor en AMD-model (Figur 18) hvor inflammation kan initiere og accelerere den normale aldersafhaengige akkumulation af affaldsstoffer i nethinden, som senere udvikler sig til druser, medførende øget lokal inflammation og med tiden tidlig og intermediaer AMD. Dette resulterer i den øgede risiko for udvikling til de invaliderende senstadier af AMD. ENGLISH SUMMARY: Age-related macular degeneration (AMD) is the most common cause of irreversible vision loss and blindness in high-income countries. It is a progressive retinal disease leading to damage of the cells responsible for central vision. The early stages of the disease are often asymptomatic, while late-stage AMD, which is divided into two entities, neovascular AMD and geographic atrophy (GA), both show vision loss, though generally with different progression rates. Drusen and pigmentary abnormalities in the retina characterise early AMD, while nAMD and GA show angiogenesis in and atrophy of the retina, respectively. The aetiology is multifactorial and, in addition to ageing, which is the most significant risk factor for developing AMD, environmental- and genetic risk factors are implicated in the pathogenesis. Research has focused on local changes in the eye where inflammation has been found to play an essential role, but studies also point to systemic alterations and especially systemic inflammation to be involved in the pathogenesis. The Philadelphia-negative myeloproliferative neoplasms (MPN) are a group of haematological cancers with an acquired genetic defect of the pluripotent haematopoietic stem cell, characterised by excess haematopoiesis of the myeloid cell lineage. The diseases have been found to evolve in a biological continuum from early cancer state, essential thrombocythemia, over polycythaemia vera (PV), to the advanced myelofibrosis stage (PMF). The symptoms in these patients are often a result of the changes in the blood composition, hyperviscosity, microvascular disturbances, and reduced tissue perfusion. The major causes of morbidity and mortality are thromboembolic- and haemorrhagic events, and leukemic transformation. A group of mutations that drive the MPNs has been identified, e.g., the JAK2V617F mutation, which results in deregulation of the JAK/STAT signal transduction pathway important, for instance, in cell differentiation and survival. A previous large register study has shown that patients with MPNs have an increased risk of neovascular AMD, and a pilot study has shown an increased prevalence of intermediate AMD. We wish to study this further in a larger scale study. Several studies have also shown that systemic inflammation plays an essential role in both the initiation and progression of the malignant cell clone in MPNs. From this knowledge, a "Human inflammation model" has been developed. Since then, the MPNs has been used as model diseases for a similar inflammation model for the development of Alzheimer's disease. In this PhD project, we would like to investigate systemic inflammation in relation to drusen presence. We will do this by comparing systemic immunological markers previously investigated in patients with AMD and compare with MPN. We are primarily interested in systemic immunological differences between patients with MPN and drusen (MPNd) and MPN with normal retinas (MPNn). This thesis consists of two main studies. Study I investigated the prevalence of retinal changes associated with AMD and the prevalence of different AMD stages in 200 patients with MPN (paper I). Study II examined immunological similarities between AMD and MPNs. This study was divided into three substudies exploring systemic markers of inflammation, ageing and angiogenesis, respectively. This was done in four types of patients: nAMD, intermediate AMD (iAMD), MPNd and MPNn. Investigating, differences between MPNd and MPNn, will make it possible to identify changes in the immune system, relevant for AMD pathogenesis. Additionally, we will compare patients with MPNs with patients with iAMD and nAMD. In study I (Paper I), we found that patients with MPNs have a significantly higher prevalence of large drusen and consequently AMD from an earlier age compared to the estimates from three large population-based studies. We also found that drusen prevalence was associated with a higher neutrophil-to-lymphocyte ratio indicating a higher level of chronic low-grade inflammation in patients with drusen compared to those without drusen. In study II (papers II, III and IV), we found immunological differences between patients with MPNd and MPNn. When we investigated markers of inflammation, we found a higher level of systemic inflammation in MPNd than MPNn. This was indicated by a higher inflammation score (based on levels of pro-inflammatory markers), a higher neutrophil-to-lymphocyte ratio, and indications of a deregulated complement system. When examining markers of ageing, we found signs of accelerated immune ageing in MPNd compared to MPNn, shown by more senescent effector memory T cells. Finally, when exploring a marker of angiogenesis, we found a lower CXCR3 expression on monocytes and T cells in nAMD compared to iAMD, MPNd and MPNn, in line with previous studies of nAMD compared to healthy controls. Further, we found decreasing CXCR3 expression over the MPN biological continuum. These studies indicate CXCR3 involvement in both nAMD and PMF, two disease stages characterised by angiogenesis and fibrosis. From the results of this PhD project, we can conclude that the prevalence of drusen and AMD is increased in patients with MPN compared to the general population. Further, our results show that systemic inflammation may play a far more essential role in AMD pathogenesis than previously anticipated. We, therefore, propose an AMD model (Figure 18) where inflammation can initiate and accelerate the normal age-dependent accumulation of debris in the retina, which later evolve into drusen, resulting in increased local inflammation, and over time early- and intermediate AMD. This results in the increased risk of developing the late debilitating stages of AMD.

New anti-angiogenic compound based on chemically modified heparin

PURPOSE

The purpose of this study was to measure the anti-angiogenic effect of N-desulfated Re-N-acetylated, a chemically modified heparin (mHep).

METHODS

In vitro assays (cell tube formation, viability, proliferation, and migration) with endothelial cells were performed after 24 h of treatment with mHep at 10, 100, and 1000 ng/mL or saline. In vivo tests were performed after laser-induced choroidal neovascularization (CNV) in rats, followed by an intravitreal injection (5 µL) of mHep (10, 100, 1000 ng/mL) or balanced salt solution. Immunofluorescence analysis of the CNV was performed after 14 days.

RESULTS

mHep produced a statistically significant reduction in cell proliferation, tube formation, and migration, without cell viability changes when compared to saline. Mean measures of CNV area were 54.84 × 10⁶ pixels/mm (± 12.41 × 10⁶), 58.77 × 10⁶ pixels/mm (± 17.52 × 10⁶), and 59.42 × 10⁶ pixels/mm (± 17.33 × 10⁶) in groups 100, 1000, and 10,000 ng/mL, respectively, while in the control group, mean area was 72.23 × 10⁶ (± 16.51 × 10⁶). The P value was 0.0065. Perimeter analysis also demonstrated statistical significance (P = 0.0235) with the mean measure of 93.55 × 10⁴, 94.23 × 10⁴, and 102 × 10⁴ in the 100 ng/mL, 1000 ng/mL, and control groups, respectively.

CONCLUSIONS

These results suggest that mHep N-DRN is a potent anti-angiogenic, anti-proliferative, and anti-migratory compound with negligible anticoagulant or hemorrhagic action and no cytotoxicity for retina cells. This compound may serve as a candidate for treating choroidal neovascularization.

Predictors of problems reported on the EQ-5D-3L dimensions among people with impaired vision in northern Portugal

BACKGROUND

The EQ-5D index often fails to detect the effect of ophthalmic diseases and sight loss. Investigating predictors of individual EQ-5D health dimensions might reveal the underlying reasons. The aim of this study was to investigate predictors of health dimension ratings obtained with the EQ-5D-3L from participants with impaired vision representing a spectrum of eye diseases.

METHODS

Observational cross-sectional study with participants recruited at four public hospitals in Portugal. Outpatients with visual acuity of 0.30 logMAR(6/12) or worse in the better-seeing eye were invited to participate. Participants completed two instruments: the EQ-5D-3L (measures participants' perceived health-related quality-of-life) and the Massof Activity Inventory (measures visual ability-ability to perform vision-related activities). This study used logistic regression models to identify factors associated with responses to the EQ-5D-3L.

RESULTS

The study included 492 participants, mean age 63.4 years (range = 18-93), 50% females. The most common diagnosis was diabetic retinopathy (37%). The mean visual acuity in the better seeing eye was 0.65 logMAR (SD = 0.48) and the mean visual ability was 0.62 logits (SD = 2.04), the correlation between the two was r = - 0.511 (p < 0.001). Mobility and self-care were the health dimensions with the fewest problems (1% reported extreme problems), anxiety and depression the dimension with the most problems (24% reported extreme problems). ROC curve analysis showed that the EQ-5D index was a poor predictor of cases of vision impairment whilst visual ability given was a good predictor of cases of vision impairment. Visual ability was an independent predictor of the response for all dimensions, higher ability was always associated with a reduced odds of reporting problems. The odds of reporting problems were increased for females in 3 out of 5 dimensions. Comorbidities, visual acuity and age-category were predictors of the odds of reporting problems for one dimension each.

CONCLUSIONS

The odds of reporting problems for the five health dimensions of the EQ-5D-3L were strongly influenced by the ability to perform vision-related activities (visual ability). The EQ-5D index showed poor performance at detecting vision impairment. These findings are informative and relevant for the clinic and for research evaluating the impact of eye diseases and disease treatments in ophthalmology.

Concept Mapping to Identify Content for a Performance-Based Measure of Low Luminance Vision-Related Activities of Daily Living

Purpose

The purpose of this study was to identify low luminance activities of daily living (ADL) relevant to adults with vision impairment using a concept-mapping approach.

Methods

“Group concept mapping” was utilized to identify specific ADLs that persons with vision impairment find challenging under low light conditions. In the first “brainstorming” phase, 24 adults with vision impairment from a range of eye conditions (mean age = 73 years, SD = 14 years) and 26 international low vision experts (mean experience = 22, SD = 11 years) generated statements to the focus prompt, “Thinking as broadly as possible, generate a list of statements detailing specific day-to-day activities a person with vision impairment might find challenging under low light conditions, such as in a poorly lit room or outside at dusk.” In the second phase, participants sorted activities by similarity and rated the importance of each activity. Multidimensional scaling and hierarchical cluster analysis were applied to produce concept maps showing clusters of prioritized activities.

Results

One hundred thirteen unique ideas/activities were generated, rated and sorted. Eight clusters were identified (from highest to lowest importance): hazard detection and safety outside; social interactions; navigation; near reading; selfcare and safety at home; distance spotting; searching around the home; and cooking and cleaning.

Conclusions

The conceptual framework and low luminance ADLs identified (the most important being hazard detection and safety outside, and social interactions) provide a basis for developing a performance-based measure of low luminance visual function.

Translational Relevance

A performance-based measure of low luminance vision-related ADLs is required for comprehensively and objectively assessing efficacy of eye treatments and low vision rehabilitation outcomes in adults with vision impairment.

The psychological impact of instrumental activities of daily living on people with simulated age-related macular degeneration

BACKGROUND

People with age-related macular degeneration (AMD) can report reduced mental health. There is also evidence that they struggle with daily tasks because of vision loss.

AIMS

The purpose of this study was to assess the psychological impact of instrumental activities of daily living on people with simulated AMD.

METHOD

Twenty-four normally sighted participants completed 12 household tasks, in a simulated home environment, under a moderate-to-severe AMD simulation. Participants' psychological state was measured through self-report questionnaires and physiological measurements related to anxiety and stress. Tasks were completed twice, under counterbalanced vision conditions (normal and simulated AMD).

RESULTS

Linear mixed models on vision condition (normal versus simulated AMD) and trial order (trial 1 versus trial 2) revealed a significant large negative effect of the AMD simulation on time to complete tasks, and the anxiety, task engagement and distress self-reports (all P < 0.024, all ω² > 0.177). There were also significant medium-large effects of trial order on time, task incompletion, task errors, and the anxiety and task engagement self-reports (all P < 0.047, all ω² > 0.130), whereby the results improved during the second attempt at the tasks. No physiological measures were significant (all P > 0.05).

CONCLUSIONS

Completing instrumental activities of daily living under an AMD simulation had a negative impact on participants' self-reported mental state. The observed trial order effects also illuminated how practice with tasks could ease anxiety and stress over time.

Scoping review of remote rehabilitation (telerehabilitation) services to support people with vision impairment

OBJECTIVE

Telerehabilitation for individuals with vision impairment aims to maintain maximum physical and/or psychological functioning through remote service delivery. This review aims to describe the type of telerehabilitation services available to people with vision impairment and summarise evidence on health-related outcomes, well-being and cost-effectiveness.

DESIGN

Scoping review.

DATA SOURCES

CINAHL Plus, MEDLINE, PsycARTICLES, PsychINFO, Embase, PubMed, HMIC and Ovid Emcare were searched, without date restrictions up to 24 May 2021. Charity and government websites, conference proceedings and clinical trial databases were also examined.

ELIGIBILITY CRITERIA

Eligible studies evaluated benefits of telerehabilitation services for adults with vision impairment. Studies were excluded if they were not available in English, or focused on distance learning of visually impaired students.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened articles and extracted data. A risk of bias analysis was performed.

OUTCOME MEASURES

Measures of benefit included performance-based assessment, patient-reported outcomes and cost-effectiveness.

RESULTS

Of 4472 articles, 10 eligible studies were included. Outcomes addressed patient satisfaction (n=4;33.3%), quality-of-life, activities of daily living and well-being (n=4;33.3%), objective visual function (n=2;16.6%) and knowledge relating to ocular symptoms (n=1;8.3%). Two studies addressed multiple outcomes. Cost-effectiveness was addressed in one article (8.3%). Patients were generally satisfied with their experiences, which had a range of positive benefits on functional and quality-of-life outcomes in areas relating to daily activities (eg, reading, making phone calls). Telerehabilitation allowed patients to undertake vision optimisation training to prevent vision deterioration. Grey literature indicated that there are no completed clinical trials relating to low vision telerehabilitation. Charity services had implemented digital skills training to help beneficiaries communicate remotely.

CONCLUSION

While acceptability of telerehabilitation was mostly high, limited real-world data are available which raises questions around the long-term desirability of this approach. Further trials are needed to evaluate telerehabilitation using a robust set of outcome measures.

PROSPERO REGISTRATION NUMBER

CRD42021254825.