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Daich Varela M, Sanders Villa A, Pontikos N, Crossland MD, Michaelides M. Digital health and wearable devices for retinal disease monitoring. Graefes Arch Clin Exp Ophthalmol 2024:10.1007/s00417-024-06634-3. [PMID: 39297890 DOI: 10.1007/s00417-024-06634-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 07/30/2024] [Accepted: 08/29/2024] [Indexed: 09/21/2024] Open
Abstract
Digital health is wielding a growing influence across all areas of healthcare, encompassing various facets such as telemedicine, artificial intelligence (AI), and electronic healthcare records. In Ophthalmology, digital health innovations can be broadly divided into four categories: (i) self-monitoring home devices and apps, (ii) virtual and augmented reality visual aids, (iii) AI software, and (iv) wearables. Wearable devices can work in the background, collecting large amounts of objective data while we do our day-to-day activities, which may be ecologically more valid and meaningful to patients than that acquired in traditional hospital settings. They can be a watch, wristband, piece of clothing, glasses, cane, smartphone in our pocket, earphones, or any other device with a sensor that we carry with us. Focusing on retinal diseases, a key challenge in developing novel therapeutics has been to prove a meaningful benefit in patients' lives and the creation of objective patient-centred endpoints in clinical trials. In this review, we will discuss wearable devices collecting different aspects of visual behaviour, visual field, central vision, and functional vision, as well as their potential implementation as outcome measures in research/clinical trial settings. The healthcare landscape is facing a paradigm shift. Clinicians have a key role of collaborating with the development and fine-tuning of digital health innovations, as well as identifying opportunities where they can be leveraged to enhance our understanding of retinal diseases and improve patient outcomes.
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Affiliation(s)
- Malena Daich Varela
- Moorfields Eye Hospital, London, UK
- UCL Institute of Ophthalmology, University College London, 11-43 Bath Street, London, EC1V 9EL, UK
| | - Alejandro Sanders Villa
- Facultad de Enfermería y Obstetricia, Universidad Nacional Autónoma de México, Mexico City, México
- Primero Salud, Mexico City, México
| | - Nikolas Pontikos
- Moorfields Eye Hospital, London, UK
- UCL Institute of Ophthalmology, University College London, 11-43 Bath Street, London, EC1V 9EL, UK
| | - Michael D Crossland
- UCL Institute of Ophthalmology, University College London, 11-43 Bath Street, London, EC1V 9EL, UK
| | - Michel Michaelides
- Moorfields Eye Hospital, London, UK.
- UCL Institute of Ophthalmology, University College London, 11-43 Bath Street, London, EC1V 9EL, UK.
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Igoe JM, Lam BL, Gregori NZ. Update on Clinical Trial Endpoints in Gene Therapy Trials for Inherited Retinal Diseases. J Clin Med 2024; 13:5512. [PMID: 39336999 PMCID: PMC11431936 DOI: 10.3390/jcm13185512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2024] [Revised: 09/05/2024] [Accepted: 09/16/2024] [Indexed: 09/30/2024] Open
Abstract
Inherited retinal diseases (IRDs) encompass a wide spectrum of rare conditions characterized by diverse phenotypes associated with hundreds of genetic variations, often leading to progressive visual impairment and profound vision loss. Multiple natural history studies and clinical trials exploring gene therapy for various IRDs are ongoing. Outcomes for ophthalmic trials measure visual changes in three main categories-structural, functional, and patient-focused outcomes. Since IRDs may range from congenital with poor central vision from birth to affecting the peripheral retina initially and progressing insidiously with visual acuity affected late in the disease course, typical outcome measures such as central visual acuity and ocular coherence tomography (OCT) imaging of the macula may not provide adequate representation of therapeutic outcomes including alterations in disease course. Thus, alternative unique outcome measures are necessary to assess loss of peripheral vision, color vision, night vision, and contrast sensitivity in IRDs. These differences have complicated the assessment of clinical outcomes for IRD therapies, and the clinical trials for IRDs have had to design novel specialized endpoints to demonstrate treatment efficacy. As genetic engineering and gene therapy techniques continue to advance with growing investment from industry and accelerated approval tracks for orphan conditions, the clinical trials must continue to improve their assessments to demonstrate safety and efficacy of new gene therapies that aim to come to market. Here, we will provide an overview of the current gene therapy approaches, review various endpoints for measuring visual function, highlight those that are utilized in recent gene therapy trials, and provide an overview of stage 2 and 3 IRD trials through the second quarter of 2024.
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Affiliation(s)
- Jane M Igoe
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Byron L Lam
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Ninel Z Gregori
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Miami Veterans Administration Medical Center, Miami, FL 33125, USA
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Jung R, Kempf M, Holocher S, Kortüm FC, Stingl K, Stingl K. Multi-luminance mobility testing after gene therapy in the context of retinal functional diagnostics. Graefes Arch Clin Exp Ophthalmol 2024; 262:601-607. [PMID: 37768368 PMCID: PMC10844143 DOI: 10.1007/s00417-023-06237-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/25/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Voretigene neparvovec (Luxturna®) is the first approved gene therapy for RPE65-linked Leber congenital amaurosis (LCA). Though individual effects are highly variable, most recipients report improved vision in everyday life. To describe such effects, visual navigation tests are now frequently used in clinical trials. However, it is still unclear how their results should be interpreted compared to conventional parameters of visual function. METHODS Seven LCA patients underwent a multi-luminance visual navigation test (Ora-VNCTM) before and 3 months after receiving Luxturna gene therapy. Their performance was rated based on the luminance level at which they passed the course. Differences between the first and second test were correlated to changes in visual acuity, full-field stimulus thresholds, chromatic pupil campimetry, and dark-adapted perimetry. RESULTS A few patients displayed notable improvements in conventional measures of visual function whereas patients with advanced retinal degeneration showed no relevant changes. Independent of these results, almost all participants improved in the visual navigation task by one or more levels. The improvement in the mobility test was best correlated to the change in full-field stimulus thresholds. Other measures of visual functions showed no clear correlation with visual navigation. DISCUSSION In patients who passed the test's more difficult levels, improved visual navigation can be attributed to the reactivation of rods. However, the performance of patients with low vision seemed to depend much more on confounding factors in the easier levels. In sum, such tests might only be meaningful for patients with better preserved visual functions.
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Affiliation(s)
- Ronja Jung
- University Eye Hospital, Center for Ophthalmology, University of Tuebingen, Elfriede-Aulhorn-Str.7, Tübingen, Germany.
| | - Melanie Kempf
- University Eye Hospital, Center for Ophthalmology, University of Tuebingen, Elfriede-Aulhorn-Str.7, Tübingen, Germany
- Center for Rare Eye Diseases, University of Tübingen, Tübingen, Germany
| | - Saskia Holocher
- University Eye Hospital, Center for Ophthalmology, University of Tuebingen, Elfriede-Aulhorn-Str.7, Tübingen, Germany
| | - Friederike C Kortüm
- University Eye Hospital, Center for Ophthalmology, University of Tuebingen, Elfriede-Aulhorn-Str.7, Tübingen, Germany
| | - Krunoslav Stingl
- University Eye Hospital, Center for Ophthalmology, University of Tuebingen, Elfriede-Aulhorn-Str.7, Tübingen, Germany
- Center for Rare Eye Diseases, University of Tübingen, Tübingen, Germany
| | - Katarina Stingl
- University Eye Hospital, Center for Ophthalmology, University of Tuebingen, Elfriede-Aulhorn-Str.7, Tübingen, Germany.
- Center for Rare Eye Diseases, University of Tübingen, Tübingen, Germany.
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Authié CN, Poujade M, Talebi A, Defer A, Zenouda A, Coen C, Mohand-Said S, Chaumet-Riffaud P, Audo I, Sahel JA. Development and Validation of a Novel Mobility Test for Rod-Cone Dystrophies: From Reality to Virtual Reality. Am J Ophthalmol 2024; 258:43-54. [PMID: 37437832 DOI: 10.1016/j.ajo.2023.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE To validate a novel mobility test (MOST, MObility Standardized Test) and performance outcomes in real (RL) and virtual (VR) environments to be used for interventional clinical studies in order to characterize vision impairment in rod-cone dystrophies, also known as retinitis pigmentosa (RP). DESIGN Prospective, interventional, noninvasive, reliability and validity analysis. METHODS We designed MOST to be used in both VR and RL and conducted 3 experimental studies with 89 participants to (1) validate the difficulty of the mobility courses (15 controls), (2) determine the optimal number of light levels and training trials (14 participants with RP), and (3) validate the reproducibility (test-retest), reliability (VR/RL), sensitivity, and construct/content validity of the test (30 participants with RP and 30 controls). A comprehensive ophthalmologic examination was performed in all subjects. Outcomes of interest included MOST performance score, visual acuity, contrast sensitivity, dark adaptation thresholds, visual field parameters, and correlation between the performance score and visual function. RESULTS The mobility courses exhibited statistically similar difficulty, and 5 trials are sufficient to control for the learning effect. MOST is highly reproducible (test-retest correlations >0.98) and reliable (correlations VR/RL = 0.98). MOST achieved a discrimination between participants with RP and controls (accuracy >95%) and between early and late stages of the disease (82.3% accuracy). The performance score is correlated with visual function parameter (0.57-0.94). CONCLUSION MOST is a validated mobility test, with the controlled learning effect, excellent reproducibility, and high agreement between RL and VR conditions, as well as sensitivity and specificity to measure disease progression and therapeutic benefit in rod-cone dystrophies.
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Affiliation(s)
- Colas Nils Authié
- From the Streetlab (C.N.A., M.P., A.T., A.D., A.Z., C.C.), Paris, France.
| | - Mylène Poujade
- From the Streetlab (C.N.A., M.P., A.T., A.D., A.Z., C.C.), Paris, France
| | - Alireza Talebi
- From the Streetlab (C.N.A., M.P., A.T., A.D., A.Z., C.C.), Paris, France; Institut de la Vision, Sorbonne Universités, INSERM, CNRS (A.T., I.A., J.-A.S.), Paris, France
| | - Alexis Defer
- From the Streetlab (C.N.A., M.P., A.T., A.D., A.Z., C.C.), Paris, France
| | - Ariel Zenouda
- From the Streetlab (C.N.A., M.P., A.T., A.D., A.Z., C.C.), Paris, France
| | - Cécilia Coen
- From the Streetlab (C.N.A., M.P., A.T., A.D., A.Z., C.C.), Paris, France
| | - Saddek Mohand-Said
- Hôpital National de la Vision des Quinze-Vingts, DHU Sight Restore, Centre de Référence Maladies Rares REFERET, INSERM-DHOS CIC 1423 (S.M.-S., P.C.-R., I.A., J.-A.S.), Paris, France
| | - Philippe Chaumet-Riffaud
- Hôpital National de la Vision des Quinze-Vingts, DHU Sight Restore, Centre de Référence Maladies Rares REFERET, INSERM-DHOS CIC 1423 (S.M.-S., P.C.-R., I.A., J.-A.S.), Paris, France
| | - Isabelle Audo
- Institut de la Vision, Sorbonne Universités, INSERM, CNRS (A.T., I.A., J.-A.S.), Paris, France; Hôpital National de la Vision des Quinze-Vingts, DHU Sight Restore, Centre de Référence Maladies Rares REFERET, INSERM-DHOS CIC 1423 (S.M.-S., P.C.-R., I.A., J.-A.S.), Paris, France
| | - José-Alain Sahel
- Institut de la Vision, Sorbonne Universités, INSERM, CNRS (A.T., I.A., J.-A.S.), Paris, France; Hôpital National de la Vision des Quinze-Vingts, DHU Sight Restore, Centre de Référence Maladies Rares REFERET, INSERM-DHOS CIC 1423 (S.M.-S., P.C.-R., I.A., J.-A.S.), Paris, France; Department of Ophthalmology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA (J.-A.S.)
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Rogers CM, Salzman MM, Li Z, Merten N, Russell LJ, Lillesand HK, Mowat FM. Subjective vision assessment in companion dogs using dogVLQ demonstrates age-associated visual dysfunction. Front Vet Sci 2023; 10:1244518. [PMID: 37662991 PMCID: PMC10469761 DOI: 10.3389/fvets.2023.1244518] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/07/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction Dim light vision as assessed by proxy and clinical tools is commonly impaired in older humans and impacts quality of life. Although proxy visual assessment tools have been developed for dogs, it is unclear if they are sensitive enough to detect subtle visual dysfunction in older dogs. We sought to determine if a newly designed proxy visual function questionnaire could detect age-associated differences in visual behaviors in varying lighting conditions in dogs. Methods A 27-item questionnaire (the dog variable lighting questionnaire, dogVLQ) was designed to assess visual behavior in dogs in different lighting settings. We conducted the dogVLQ, a previously validated visual function questionnaire the dog vision impairment score and performed light- and dark-adapted electroretinography (ERG) on a subset of dogs. Questionnaire scores were analyzed for dog age associations using correlation analysis. Results Questionnaire responses from 235 dog owners were obtained (122 female, 112 male dogs), 79 of which underwent ERG (43 female, 36 male dogs). Bright light visual behavior was significantly associated with light-adapted bright flash ERG amplitudes, visual behavior in near darkness was associated with dark-adapted ERG amplitudes. The dogVLQ identified worse vision in older dogs in bright light, dim light, and darkness; predicted onset was younger for vision in near darkness. Older dogs had more difficulty navigating transitions between lighting conditions. Discussion Subjective dog owner assessment of visual function associates with objective measurement of retinal function in dogs and supports reduced vision-mediated behaviors in older dogs.
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Affiliation(s)
- Callie M. Rogers
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin–Madison, Madison, WI, United States
| | - Michele M. Salzman
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin–Madison, Madison, WI, United States
| | - Zhanhai Li
- Department of Biostatistics and Medical Informatics, University of Wisconsin–Madison, Madison, WI, United States
| | - Natascha Merten
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, United States
- Department of Medicine (Geriatrics and Gerontology), School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, United States
| | - Leah J. Russell
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin–Madison, Madison, WI, United States
| | - Hannah K. Lillesand
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin–Madison, Madison, WI, United States
| | - Freya M. Mowat
- Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin–Madison, Madison, WI, United States
- Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, United States
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Gobeille MR, Fujiwara K, Massof RW. Application of Rasch Analysis to Timed Instrumental Activities of Daily Living in Low Vision: A Validation Study. Optom Vis Sci 2023; 100:397-405. [PMID: 37129852 PMCID: PMC10330376 DOI: 10.1097/opx.0000000000002026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
SIGNIFICANCE This work validates Rasch analysis of a performance-based low vision outcome measure evaluated in patients' own homes to ensure real-world relevance. Inclusion of sources of variance from the patient's home environment in functional outcome measures introduced nonuniform variance in measurements but did not preclude estimation of valid measures. PURPOSE This study aimed to validate Rasch analysis of a performance-based outcome measure with real-world relevance. METHODS Low vision patients (N = 161) receiving services from an occupational therapist performed Timed Instrumental Activity of Daily Living (TIADL) tasks in their homes. Rasch analysis was applied to error count and performance time data. Internal validity was assessed with evaluations of the accuracy and precision of estimated measures. External validity was assessed by comparing TIADL measures with measures estimated from the Activity Inventory (i.e., from self-reported difficulty ratings). RESULTS Task measures were well targeted to person measures estimated from task performance time but were poorly targeted for measures estimated from task performance errors, for which most task trials (72%) were performed without error at baseline. Error-based person measures had larger standard errors with a smaller pseudo- R2 than time-based person or task measures and error-based task measures. Person measure infits for time- and error-based estimates conformed to expected values. The linear regressions between time-based person and task measures and corresponding error-based estimates had slopes of approximately 0.5, an observation consistent with larger estimation error variance for error-based measures than for time-based measures. Time-based TIADL person measures ( x ) and Activity Inventory person measures (estimated from all items, y ) were colinear but weakly correlated ( R = 0.19). CONCLUSIONS Functional ability measures estimated from performance times of instrumental activity of daily living tasks in patients' homes demonstrate good internal and external validity. The ceiling effect from the infrequency of task performance errors in our data set limits use of TIADL error data to measure rehabilitation outcomes.
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Affiliation(s)
| | - Kyoko Fujiwara
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert W Massof
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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Stingl K, Kempf M, Jung R, Kortüm F, Righetti G, Reith M, Dimopoulos S, Ott S, Kohl S, Stingl K. Therapy with voretigene neparvovec. How to measure success? Prog Retin Eye Res 2023; 92:101115. [PMID: 36096933 DOI: 10.1016/j.preteyeres.2022.101115] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/17/2022] [Accepted: 08/19/2022] [Indexed: 02/01/2023]
Abstract
Retinal gene supplementation therapy such as the first approved one, voretigene neparvovec, delivers a functioning copy of the missing gene enabling the protein transcription in retinal cells and restore visual functions. After gene supplementation for the genetic defect, a complex network of functional regeneration is the consequence, whereas the extent is very individualized. Diagnostic and functional testings that have been used routinely by ophthalmologists so far to define the correct diagnosis, cannot be applied in the new context of defining small, sometimes subtle changes in visual functions. New view on retinal diagnostics is needed to understand this processes that define safety and efficacy of the treatment. Not only does vision have many aspects that must be addressed by specific evaluations and imaging techniques, but objective readouts of local retinal function for rods and cones separately have been an unmet need until recently. A reliable test-retest variability is necessary in rare diseases such as inherited retinal dystrophies, because statistics are often not applicable due to a low number of participants. Methods for a reliable individual evaluation of the therapy success are needed. In this manuscript we present an elaboration on retinal diagnostics combining psychophysics (eg. full-field stimulus threshold or dark adapted perimetry) as well as objective measures for local retinal function (eg. photopic and scotopic chromatic pupil campimetry) and retinal imaging for a meaningful workflow to apply in evaluation of the individual success in patients receiving gene therapy for photoreceptor diseases.
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Affiliation(s)
- Krunoslav Stingl
- Center for Ophthalmology, University Eye Hospital, University of Tuebingen, Tuebingen, Germany; Center for Rare Eye Diseases, University of Tuebingen, Tuebingen, Germany.
| | - Melanie Kempf
- Center for Ophthalmology, University Eye Hospital, University of Tuebingen, Tuebingen, Germany; Center for Rare Eye Diseases, University of Tuebingen, Tuebingen, Germany.
| | - Ronja Jung
- Center for Ophthalmology, University Eye Hospital, University of Tuebingen, Tuebingen, Germany.
| | - Friederike Kortüm
- Center for Ophthalmology, University Eye Hospital, University of Tuebingen, Tuebingen, Germany.
| | - Giulia Righetti
- Center for Ophthalmology, University Eye Hospital, University of Tuebingen, Tuebingen, Germany.
| | - Milda Reith
- Center for Ophthalmology, University Eye Hospital, University of Tuebingen, Tuebingen, Germany.
| | - Spyridon Dimopoulos
- Center for Ophthalmology, University Eye Hospital, University of Tuebingen, Tuebingen, Germany.
| | - Saskia Ott
- Center for Ophthalmology, University Eye Hospital, University of Tuebingen, Tuebingen, Germany.
| | - Susanne Kohl
- Molecular Genetics Laboratory, Institute for Ophthalmic Research, Center for Ophthalmology, University of Tuebingen, Tuebingen, Germany.
| | - Katarina Stingl
- Center for Ophthalmology, University Eye Hospital, University of Tuebingen, Tuebingen, Germany; Center for Rare Eye Diseases, University of Tuebingen, Tuebingen, Germany.
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Bentley SA, Black AA, Hindmarsh GP, Owsley C, Wood JM. Concept Mapping to Identify Content for a Performance-Based Measure of Low Luminance Vision-Related Activities of Daily Living. Transl Vis Sci Technol 2022; 11:27. [PMID: 36166222 PMCID: PMC9526368 DOI: 10.1167/tvst.11.9.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Sharon A Bentley
- School of Optometry and Vision Science, Centre of Vision and Eye Research, Queensland University of Technology, Brisbane, Australia
| | - Alex A Black
- School of Optometry and Vision Science, Centre of Vision and Eye Research, Queensland University of Technology, Brisbane, Australia
| | - Gregory P Hindmarsh
- School of Optometry and Vision Science, Centre of Vision and Eye Research, Queensland University of Technology, Brisbane, Australia
| | - Cynthia Owsley
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joanne M Wood
- School of Optometry and Vision Science, Centre of Vision and Eye Research, Queensland University of Technology, Brisbane, Australia
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Roman AJ, Cideciyan AV, Wu V, Mascio AA, Krishnan AK, Garafalo AV, Jacobson SG. Mobility test to assess functional vision in dark-adapted patients with Leber congenital amaurosis. BMC Ophthalmol 2022; 22:266. [PMID: 35701753 PMCID: PMC9195222 DOI: 10.1186/s12886-022-02475-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 06/01/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Inherited retinal degenerations (IRDs) affect daylight and night vision to different degrees. In the current work, we devise a method to quantify mobility under dark-adapted conditions in patients with severe childhood blindness due to Leber congenital amaurosis (LCA). Mobility thresholds from two different LCA genotypes are compared to dark-adapted vision measurements using the full-field stimulus test (FST), a conventional desktop outcome measure of rod vision. METHODS A device consisting of vertical LED strips on a plane resembling a beaded curtain was programmed to produce a rectangular pattern target defining a 'door' of varying luminance that could appear at one of three positions. Mobility performance was evaluated by letting the subject walk from a fixed starting position ~ 4 m away from the device with instructions to touch the door. Success was defined as the subject touching within the 'door' area. Ten runs were performed and the process was repeated for different levels of luminance. Tests were performed monocularly in dark-adapted and dilated eyes. Results from LCA patients with the GUCY2D and CEP290 genotypes and normal subjects were analyzed using logistic regression to estimate the mobility threshold for successful navigation. The relation of thresholds for mobility, FST and visual acuity were quantified using linear regression. RESULTS Normal subjects had mobility thresholds near limits of dark-adapted rod vision. GUCY2D-LCA patients had a wide range of mobility thresholds from within 1 log of normal to greater than 8 log abnormal. CEP290-LCA patients had abnormal mobility thresholds that were between 5 and 6 log from normal. Sensitivity loss estimates using FST related linearly to the mobility thresholds which were not correlated with visual acuity. CONCLUSIONS The mobility task we developed can quantify functional vision in severely disabled patients with LCA. Taken together with other outcome measures of rod and cone photoreceptor-mediated vision, dark-adapted functional vision should provide a more complete understanding of the natural history and effects of treatment in patients with LCA.
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Affiliation(s)
- Alejandro J. Roman
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, 51 North 39th St, PA 19104 Philadelphia, USA
| | - Artur V. Cideciyan
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, 51 North 39th St, PA 19104 Philadelphia, USA
| | - Vivian Wu
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, 51 North 39th St, PA 19104 Philadelphia, USA
| | - Abraham A. Mascio
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, 51 North 39th St, PA 19104 Philadelphia, USA
| | - Arun K. Krishnan
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, 51 North 39th St, PA 19104 Philadelphia, USA
| | - Alexandra V. Garafalo
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, 51 North 39th St, PA 19104 Philadelphia, USA
| | - Samuel G. Jacobson
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, 51 North 39th St, PA 19104 Philadelphia, USA
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Massof RW. Patient-Reported Measures of the Effects of Vision Impairments and Low Vision Rehabilitation on Functioning in Daily Life. Annu Rev Vis Sci 2022; 8:217-238. [PMID: 35417256 DOI: 10.1146/annurev-vision-100620-022121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The quantification of vision impairments dates to the mid-nineteenth century with standardization of visual acuity and visual field measures in the eye clinic. Attempts to quantify the impact of vision impairments on patients' lives did not receive clinical attention until the close of the twentieth century. Although formal psychometric theories and measurement instruments were well developed and commonplace in educational testing, as well as in various areas in psychology and rehabilitation medicine, the late start applying them to clinical vision research created a vacuum that invited poorly developed and poorly functioning instruments and analytic methods. Although this research is still burdened with legacy instruments, mandates by regulatory agencies to include the patients' perspectives and preferences in the evaluation of clinical outcomes have stimulated the development and validation of self-report instruments grounded in modern psychometric theory and methods. Here I review the progress and accomplishments of applying modern psychometrics to clinical vision research. Expected final online publication date for the Annual Review of Vision Science, Volume 8 is September 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Robert W Massof
- Lions Vision Research and Rehabilitation Center, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA;
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Daich Varela M, Georgiou M, Hashem SA, Weleber RG, Michaelides M. Functional evaluation in inherited retinal disease. Br J Ophthalmol 2021; 106:1479-1487. [PMID: 34824084 DOI: 10.1136/bjophthalmol-2021-319994] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/17/2021] [Indexed: 11/03/2022]
Abstract
Functional assessments are a fundamental part of the clinical evaluation of patients with inherited retinal diseases (IRDs). Their importance and impact have become increasingly notable, given the significant breadth and number of clinical trials and studies investigating multiple avenues of intervention across a wide range of IRDs, including gene, pharmacological and cellular therapies. Moreover, the fact that many clinical trials are reporting improvements in vision, rather than the previously anticipated structural stability/slowing of degeneration, makes functional evaluation of primary relevance. In this review, we will describe a range of methods employed to characterise retinal function and functional vision, beginning with tests variably included in the clinic, such as visual acuity, electrophysiological assessment and colour discrimination, and then discussing assessments often reserved for clinical trials/research studies such as photoaversion testing, full-field static perimetry and microperimetry, and vision-guided mobility testing; addressing perimetry in greatest detail, given it is commonly a primary outcome metric. We will focus on how these tests can help diagnose and monitor particular genotypes, also noting their limitations/challenges and exploring analytical methodologies for better exploiting functional measurements, as well as how they facilitate patient inclusion and stratification in clinical trials and serve as outcome measures.
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Affiliation(s)
- Malena Daich Varela
- UCL Institute of Ophthalmology, University College London, London, UK.,Moorfields Eye Hospital City Road Campus, London, UK
| | - Michalis Georgiou
- UCL Institute of Ophthalmology, University College London, London, UK.,Moorfields Eye Hospital City Road Campus, London, UK.,Department of Ophthalmology, Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Shaima A Hashem
- UCL Institute of Ophthalmology, University College London, London, UK.,Moorfields Eye Hospital City Road Campus, London, UK
| | - Richard G Weleber
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Michel Michaelides
- UCL Institute of Ophthalmology, University College London, London, UK .,Moorfields Eye Hospital City Road Campus, London, UK
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12
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Assessing Photoreceptor Status in Retinal Dystrophies: From High-Resolution Imaging to Functional Vision. Am J Ophthalmol 2021; 230:12-47. [PMID: 34000280 PMCID: PMC8682761 DOI: 10.1016/j.ajo.2021.04.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 01/05/2023]
Abstract
Purpose To describe the value of integrating phenotype/genotype data, disease staging, and evaluation of functional vision in patient-centered management of retinal dystrophies. Methods (1) Cross-sectional structure-function and retrospective longitudinal studies to assess the correlations between standard fundus autofluorescence (FAF), optical coherence tomography, visual acuity (VA), and perimetry (visual field [VF]) examinations to evaluate photoreceptor functional loss in a cohort of patients with rod-cone dystrophy (RCD); (2) flood-illumination adaptive optics (FIAO) imaging focusing on photoreceptor misalignment and orientation of outer segments; and (3) evaluation of the impact of visual impairment in daily life activities, based on functional (visual and mobility) vision assessment in a naturalistic environment in visually impaired subjects with RCD and subjects treated with LuxturnaⓇ for RPE65-related Leber congenital amaurosis before and after therapy. Results The results of the cross-sectional transversal study showed that (1) VA and macular sensitivity were weakly correlated with the structural variables; and (2) functional impairment (VF) was correlated with reduction of anatomical markers of photoreceptor structure and increased width of autofluorescent ring. The dimensions of the ring of increased FAF evolved faster. Other criteria that differed among groups were the lengths of the ellipsoid zone, the external limiting membrane, and the foveal thickness. FIAO revealed a variety of phenotypes: paradoxical visibility of foveal cones; heterogeneous brightness of cones; dim, inner segment–like, and RPE-like mosaic. Directional illumination by varying orientation of incident light (Stiles-Crawford effect) and the amount of side illumination (gaze-dependent imaging) affected photoreceptor visibility. Mobility assessment under different lighting conditions showed correlation with VF, VA, contrast sensitivity (CS), and dark adaptation, with different predictive values depending on mobility study paradigms and illumination level. At high illumination level (235 lux), VF was a predictor for all mobility performance models. Under low illumination (1 and 2 lux), VF was the most significant predictor of mobility performance variables, while CS best explained the number of collisions and segments. In subjects treated with LuxturnaⓇ, a very favorable impact on travel speed and reduction in the number of collisions, especially at low luminance, was observable 6 months following injection, in both children and adults. Conclusions Our results suggest the benefit of development and implementation of quantitative and reproducible tools to evaluate the status of photoreceptors and the impact of both visual impairment and novel therapies in real-life conditions. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.
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13
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Chung DC, Birch DG, MacLaren RE. Endpoints for Measuring Efficacy in Clinical Trials for Inherited Retinal Disease. Int Ophthalmol Clin 2021; 61:63-78. [PMID: 34584045 DOI: 10.1097/iio.0000000000000388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Roman AJ, Cideciyan AV, Wu V, Garafalo AV, Jacobson SG. Full-field stimulus testing: Role in the clinic and as an outcome measure in clinical trials of severe childhood retinal disease. Prog Retin Eye Res 2021; 87:101000. [PMID: 34464742 DOI: 10.1016/j.preteyeres.2021.101000] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/24/2021] [Accepted: 08/27/2021] [Indexed: 12/27/2022]
Abstract
Disease mechanisms have become better understood in previously incurable forms of early-onset severe retinal dystrophy, such as Leber congenital amaurosis (LCA). This has led to novel treatments and clinical trials that have shown some success. Standard methods to measure vision were difficult if not impossible to perform in severely affected patients with low vision and nystagmus. To meet the need for visual assays, we devised a psychophysical method, which we named full-field stimulus testing (FST). From early versions based on an automated perimeter, we advanced FST to a more available light-emitting diode platform. The journey from invention to use of such a technique in our inherited retinal degeneration clinic is reviewed and many of the lessons learned over the 15 years of application of FST are explained. Although the original purpose and application of FST was to quantify visual thresholds in LCA, there are rare opportunities for FST also to be used beyond LCA to measure aspects of vision in other inherited retinal degenerations; examples are given. The main goal of the current review, however, remains to enable investigators studying and treating LCA to understand how to best use FST and how to reduce artefact and confounding complexities so the test results become more valuable to the understanding of LCA diseases and results of novel interventions.
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Affiliation(s)
- Alejandro J Roman
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Artur V Cideciyan
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Vivian Wu
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Alexandra V Garafalo
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Samuel G Jacobson
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
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15
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Tuohy GP, Megaw R. A Systematic Review and Meta-Analyses of Interventional Clinical Trial Studies for Gene Therapies for the Inherited Retinal Degenerations (IRDs). Biomolecules 2021; 11:760. [PMID: 34069580 PMCID: PMC8160708 DOI: 10.3390/biom11050760] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/04/2021] [Accepted: 05/08/2021] [Indexed: 12/13/2022] Open
Abstract
IRDs are one of the leading causes of visual loss in children and young adults. Mutations in over 271 genes lead to retinal dysfunction, degeneration and sight loss. Though no cure exists, gene augmentation therapy has brought hope to the field. This systematic review sought to assess the efficacy of available gene therapy treatments for IRDs. Databases and public resources were searched for randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs). Standard methodological procedures were used, including a risk-of-bias assessment. One RCT and five NRSIs were assessed, all for adeno-associated virus two (AAV2)-mediated treatment of RPE-specific 65 kDa (RPE65)-associated LCA (Leber congenital amaurosis). Five outcomes were reported for meta-analyses. Modest improvements in visual acuity, ambulatory navigation/mobility testing or central retinal thickness was observed. There was significant improvement in red and blue light full-field stimulus testing (FST) (red light risk ratio of 1.89, treated v control, p = 0.04; and blue light risk ratio of 2.01, treated v control, p = 0.001). Study design assessment using a ROBIN-I tool (Cochrane Library) showed risk-of-bias judgement to be "low/moderate", whilst there were "some concerns" for the RCT using a RoB-2 tool (Cochrane Library). Although comparison by meta-analysis is compromised by, amongst other issues, a variable amount of vector delivered in each trial, FST improvements demonstrate a proof-of-principle for treating IRDs with gene therapy.
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Affiliation(s)
- Gearóid P. Tuohy
- MRC Human Genetics Unit, University of Edinburgh, Western General Hospital, Edinburgh EH4 2XU, UK;
| | - Roly Megaw
- MRC Human Genetics Unit, University of Edinburgh, Western General Hospital, Edinburgh EH4 2XU, UK;
- Princess Alexandra Eye Pavilion, NHS Lothian, Edinburgh EH3 9HA, UK
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16
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Georgiou M, Fujinami K, Michaelides M. Inherited retinal diseases: Therapeutics, clinical trials and end points-A review. Clin Exp Ophthalmol 2021; 49:270-288. [PMID: 33686777 DOI: 10.1111/ceo.13917] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/22/2021] [Accepted: 03/01/2021] [Indexed: 12/18/2022]
Abstract
Inherited retinal diseases (IRDs) are a clinically and genetically heterogeneous group of disorders characterised by photoreceptor degeneration or dysfunction. These disorders typically present with severe vision loss that can be progressive, with disease onset ranging from congenital to late adulthood. The advances in genetics, retinal imaging and molecular biology, have conspired to create the ideal environment for establishing treatments for IRDs, with the first approved gene therapy and the commencement of multiple clinical trials. The scope of this review is to familiarise clinicians and scientists with the current management and the prospects for novel therapies for: (1) macular dystrophies, (2) cone and cone-rod dystrophies, (3) cone dysfunction syndromes, (4) Leber congenital amaurosis, (5) rod-cone dystrophies, (6) rod dysfunction syndromes and (7) chorioretinal dystrophies. We also briefly summarise the investigated end points for the ongoing trials.
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Affiliation(s)
- Michalis Georgiou
- UCL Institute of Ophthalmology, University College London, London, UK.,Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Kaoru Fujinami
- UCL Institute of Ophthalmology, University College London, London, UK.,Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Laboratory of Visual Physiology, Division of Vision Research, National Institute of Sensory Organs, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.,Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Michel Michaelides
- UCL Institute of Ophthalmology, University College London, London, UK.,Moorfields Eye Hospital NHS Foundation Trust, London, UK
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