Phase 1 Study of JNJ-81201887 Gene Therapy in Geographic Atrophy Secondary to Age-Related Macular Degeneration

PURPOSE

To evaluate the safety and tolerability of a single intravitreal injection of JNJ-81201887 (JNJ-1887) in patients with geographic atrophy (GA) secondary to advanced dry age-related macular degeneration (AMD).

DESIGN

Phase 1, open-label, single-center, first-in-human clinical study.

PARTICIPANTS

Adult patients (≥50 years of age) with GA secondary to AMD in the study-treated eye (treated eye) with Snellen best-corrected visual acuity of 20/200 or worse in the treated eye (20/80 or worse after the first 3 patients), a total GA lesion size between 5 and 20 mm2 (2-8 disc area), and best-corrected visual acuity of 20/800 or better in fellow, nontreated eye were included.

METHODS

Patients (n = 17) were enrolled sequentially into low-dose (3.56 × 1010 viral genome/eye; n = 3), intermediate-dose (1.07 × 1011 viral genome/eye; n = 3), and high-dose (3.56 × 1011 viral genome/eye; n = 11) cohorts without steroid prophylaxis and assessed for safety and tolerability over 24 months.

MAIN OUTCOME MEASURES

Safety and tolerability outcomes included assessment of ocular and nonocular treatment-emergent adverse events (AEs) over 24 months. Secondary outcomes included GA lesion size and growth rate.

RESULTS

Baseline patient characteristics were consistent with the disease under study, and all enrolled patients demonstrated foveal center-involved GA. JNJ-81201887 was well-tolerated across all cohorts, with no dose-limiting AEs. No serious or systemic AEs related to study intervention occurred. Overall, 5 of 17 patients (29%) experienced 5 events of mild ocular inflammation related to study treatment; examination findings in all resolved, and AEs resolved in 4 of 5 patients after topical steroids or observation. One unresolved vitritis event, managed with observation, occurred in a patient with an unrelated fatal AE. No endophthalmitis or new-onset choroidal neovascularization was reported. Geographic atrophy lesion growth rate was similar among all cohorts over 24 months. For treated eyes in the high-dose cohort, GA lesion growth rate showed continued decline through 24 months, with a reduction in mean square root lesion growth from 0.211 mm at months 0 through 6 to 0.056 mm at months 18 through 24.

CONCLUSIONS

All 3 studied doses of JNJ-1887 showed a manageable safety profile through 24 months of follow-up. Further investigation of JNJ-1887 for the treatment of GA is warranted.

FINANCIAL DISCLOSURE(S)

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

Challenges and opportunities of developing small-molecule therapies for age-related macular degeneration

Age-related macular degeneration (AMD) is the leading cause of vision loss in senior adults. The disease can be categorized into two types: wet AMD and dry AMD. Wet AMD, also known as exudative or neovascular AMD, is less common but more severe than dry AMD and is responsible for 90% of the visual impairment caused by AMD and affects 20 million people worldwide. Current treatment options mainly involve biologics that inhibit the vascular endothelial growth factor or complement pathways. However, these treatments have limitations such as high cost, injection-related risks, and limited efficacy. Therefore, new therapeutic targets and strategies have been explored to improve the outcomes of patients with AMD. A promising approach is the use of small-molecule drugs that modulate different factors involved in AMD pathogenesis, such as tyrosine kinases and integrins. Small-molecule drugs offer advantages, such as oral administration, low cost, good penetration, and increased specificity for the treatment of wet and dry AMD. This review summarizes the current status and prospects of small-molecule drugs for the treatment of wet AMD. These advances are expected to support the development of effective and targeted treatments for patients with AMD.

Head-mounted digital metamorphopsia suppression as a countermeasure for macular-related visual distortions for prolonged spaceflight missions and terrestrial health

During long-duration spaceflight, astronauts are exposed to various risks including spaceflight-associated neuro-ocular syndrome, which serves as a risk to astronaut vision and a potential physiological barrier to future spaceflight. When considering exploration missions that may expose astronauts to longer periods of microgravity, radiation exposure, and natural aging processes during spaceflight, more severe changes to functional vision may occur. The macula plays a critical role in central vision and disruptions to this key area in the eye may compromise functional vision and mission performance. In this article, we describe the development of a countermeasure technique to digitally suppress monocular central visual distortion with head-mounted display technology. We report early validation studies with this noninvasive countermeasure in individuals with simulated metamorphopsia. When worn by these individuals, this emerging wearable countermeasure technology has demonstrated a suppression of monocular visual distortion. We describe the considerations and further directions of this head-mounted technology for both astronauts and aging individuals on Earth.

Factors associated with access to healthcare services for older adults with limited activities of daily living

Background

Limited studies focused on the situation and related factors of access to healthcare services for older adults with limited activities of daily living (ADL) in China. This study explores factors associated with access to healthcare services of them based on Andersen's healthcare utilization model (namely, need, predisposing, and enabling dimensions).

Methods

A total of 3,980 participants aged 65 years and older adults with limited ADL from the latest wave (2018) of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) were included. Binary logistic regression was used to explore the influencing factors.

Results

Factors in enabling dimension were associated with access to healthcare services for older adults with limited ADL. Those who lived with better economic status (fair vs poor, OR = 2.98, P < 0.01; rich vs poor, OR = 7.23, P = 0.01), could afford daily life (yes vs no, OR = 2.33, P = 0.03), and lived in the eastern or central region of China (eastern vs western, OR = 2.91, P < 0.01; central vs western, OR = 2.40, P = 0.02) could access to healthcare services more easily. However, factors in predisposing dimension and need dimension showed no statistical significance. Meanwhile, inconvenience in the movement was the major barrier reported by some participants for not going to the hospital when they got sick.

Conclusion

Access to healthcare services for older adults with ADL limitation was mainly related to the factors of economic status, affordability for daily life, and living regions in enabling dimension. Strategies focused on health insurance, healthcare system, barrier-free facilities, and social support were proposed to increase the access to healthcare services for participants, which could benefit their health.

A clinical perspective on the expanding role of artificial intelligence in age-related macular degeneration

In recent years, there has been intense development of artificial intelligence (AI) techniques, which have the potential to improve the clinical management of age-related macular degeneration (AMD) and facilitate the prevention of irreversible vision loss from this condition. Such AI techniques could be used as clinical decision support tools to: (i) improve the detection of AMD by community eye health practitioners, (ii) enhance risk stratification to enable personalised monitoring strategies for those with the early stages of AMD, and (iii) enable early detection of signs indicative of possible choroidal neovascularisation allowing triaging of patients requiring urgent review. This review discusses the latest developments in AI techniques that show promise for these tasks, as well as how they may help in the management of patients being treated for choroidal neovascularisation and in accelerating the discovery of new treatments in AMD.

Seeing Beyond Anatomy: Quality of Life with Geographic Atrophy

Quality of life (QoL) is a complex idea without a clear consensus definition. Generally speaking, QoL refers to several subjective measures of wellbeing that vary by individual and circumstance. QoL can decline noticeably as a disease progresses. This is particularly true for geographic atrophy (GA), an advanced form of age-related macular degeneration. GA leads to vision loss for which there is no currently approved pharmacological treatment. There is a lack of qualitative, patient-driven research on QoL in GA. There is also limited information available to both patients and physicians about GA, existing support groups and available assistive technologies. To address this, we have collated the experiences of a person with GA and those of her partner and carer with the current literature on QoL in GA. We have also outlined some of the wide range of developing technologies available to help people with GA carry out daily tasks and hobbies. It is clear that support, whether through informal or structured care, is vital to the wellbeing of people with GA. Despite this, the general public are often unaware of care work, which may result in this integral role being undervalued and under acknowledged. Furthermore, it is apparent that the general public have fundamental misunderstandings around what vision loss entails and are unaware that blindness is a vast spectrum. This feeds into the seemingly paradoxical mix of isolation and dependence on others that often results from GA and vision loss. Through this qualitative examination of a patient's experiences, we hope to inform and educate both patients and physicians about GA as well as precipitate discussion around the frameworks that should be in place to support both newly diagnosed and long-term patients with GA and other retinal diseases. Seeing beyond anatomy: quality of life with geographic atrophy (WMV 29479 kb).

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Translational Relevance

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

Psychological and Psychosocial Interventions for Depression and Anxiety in Patients With Age-Related Macular Degeneration: A Systematic Review

OBJECTIVE

To review the current literature on psychosocial and psychological interventions to prevent and treat depression and anxiety in patients with age-related macular degeneration (AMD).

METHODS

The authors conducted a systematic review of literature evaluating psychosocial and psychological interventions for depression and anxiety in patients with AMD. Primary searches of PubMed, Cochrane library, EMBASE, Global Health, Web of Science, EBSCO, and Science Direct were conducted to include all articles published up to April 21, 2018.

RESULTS

Of a total of 398 citations retrieved, the authors selected 12 eligible studies published between 2002 and 2016. The authors found nine randomized controlled trials (RCT), and three non-randomized intervention (NRI) studies. RCT studies suggested that interventions using group self-management techniques and individual behavioral activation plus low vision rehabilitation can be effective to treat and prevent depression in patients with AMD, and one study suggested that a stepped-care intervention using cognitive-behavioral techniques can be effective to manage anxiety and depression over time. NRI studies highlighted a positive effect of self-help and emotion-focused interventions to reduce depression.

CONCLUSION

Clinical practice with patients with AMD can rely on some tailored cognitive-behavioral therapeutic protocols to improve patients' mental health, but further clinical trials will generate the necessary evidence-based knowledge to improve those therapeutic techniques and offer additional tailored interventions for patients with AMD.

Rehabilitation needs and activity limitations of adults with a visual impairment entering a low vision rehabilitation service in England

PURPOSE

To evaluate outcome measures of the Participation and Activity Inventory (PAI) in a sample of adults with acquired visual impairment entering vision rehabilitation. Both Priority Scores, indicating level of rehabilitative need, and Person Measures, indicating goal difficulty, were considered.

METHODS

Participants were newly registered adults with visual impairment within Leicestershire, United Kingdom. The importance and difficulty of 48 goals of the PAI were assessed, as were demographic factors, clinical visual function (visual acuity, contrast sensitivity, reading function) and psychosocial function (adjustment to visual loss, depression, anxiety and fear of falling). Priority scores were calculated as the product of importance and difficulty of each goal. All questionnaires were Rasch analysed, and person and item measures of perceived difficulty with goals were derived.

RESULTS

Sixty people (mean age ± S.D. = 75.8 ± 13.8 years) took part. PAI goals with greatest rehabilitative need were reading (6.82 ± 2.91), mobility outdoors (6.55 ± 3.92), mobility indoors within an unfamiliar environment (5.52 ± 3.93) and writing (5.27 ± 3.02). Greater rehabilitative need was associated with younger age (β = -0.46, p < 0.001), and with higher depressive symptomatology (β = 0.35, p < 0.01; model R² 34%). Goals with greatest difficulty were mending clothing (-1.95 ± 0.35 logits) and hobbies and crafts (-1.32 ± 0.23 logits). Greater difficulty was associated with higher depressive symptomatology (β = 0.39, p < 0.001), lower visual acuity (β = 0.42, p < 0.001) and lower adjustment of visual loss (β = 0.31, p < 0.01; model R² 53%).

CONCLUSIONS

Key rehabilitation needs for adults at entry to services require both optical and non-optical interventions. As rehabilitative need was not associated with the level of visual impairment, eyecare professionals should not wait until the end of medical treatment before referral for support. Similarly, rehabilitative need was associated with younger age, indicating the importance to refer younger people with sight loss at an early stage. The use of structured assessment, such as the PAI, ensures goals that have an impact upon quality of life are specifically identified. Depression screening on entry to rehabilitation is relevant as it predicts both perceived difficulty and rehabilitative need.

Cultured Human Retinal Pigment Epithelial (hRPE) Sheets: A Search for Suitable Storage Conditions

The advancement of human retinal pigment epithelial cell (hRPE) replacement therapy is partly dependent on optimization of cell culture, cell preservation, and storage medium. This study was undertaken to search for a suitable storage temperature and storage medium for hRPE. hRPE monolayer sheets were cultured under standard conditions at 37°C and then randomized for storage at six temperatures (4, 16, 20, 24, 28, and 37°C) for 7 days. After revealing a suitable storage temperature, hRPE sheets were subsequently stored with and without the silk protein sericin added to the storage medium. Live/dead assay, light microscopy, pH, and phenotypic expression of various proteins were used to assess cell cultures stored at different temperatures. After 7 days of storage, hRPE morphology was best preserved at 4°C. Addition of sericin to the storage medium maintained the characteristic morphology of the preserved cells, and improved pigmentation and levels of pigmentation-related proteins in the cultured hRPE sheets following a 7-day storage period at 4°C.

Depressive Symptoms and Quality of Life in Age-related Macular Degeneration Based on Korea National Health and Nutrition Examination Survey (KNHANES)

Purpose

This study was conducted to investigate the depressive symptoms and quality of life (QOL) in patients with age-related macular degeneration (AMD) using data obtained from the Korea National Health and Nutritional Examination Survey V-2 (KNHANES V-2) conducted in 2011.

Methods

This was a population-based, cross-sectional study that selected 329 participants from the fifth KNHANES (2011) who were diagnosed with AMD by an ophthalmologist based on fundus photography. The prevalence of depressive symptoms and the health-related QOL (using EuroQol indices) in this cohort were also estimated. Factors associated with depressive symptoms, including socioeconomic status, QOL indices, and associated chronic diseases, were investigated using multivariate regression models.

Results

Depressive symptoms were observed more frequently in AMD patients than in non-AMD controls (p = 0.013). Among the total 329 AMD participants, 65 (19.8%) had depressive symptoms. There were 16 males (24.6%) and 49 females (75.4%). Upon multivariate analysis, significant factors found to be associated with depressive symptoms were female gender (odds ratio [OR], 2.082; 95% confidence interval [CI], 1.001 to 4.330), being in the “dependent” group for activities of daily living (OR, 4.638; 95% CI, 2.061 to 10.435), and having “some problems” in the “anxiety-depression” dimension of the EQ-5D (OR, 7.704; 95% CI, 1.890 to 31.408).

Conclusions

Female gender and being dependent on others for activities of daily living increased the association of depressive symptoms in this cohort of AMD participants. Screening for depressive symptoms in East Asian AMD patients with these characteristics should be an important component of their care.

Measurement of Perceived Stress in Age-Related Macular Degeneration

PURPOSE

To validate the Perceived Stress Scale (PSS) in patients with age-related macular degeneration (AMD) using Rasch analysis.

METHODS

Study participants with AMD were recruited from the retina service of the Department of Ophthalmology at the Ohio State University during clinical visits for treatment or observation. Visual acuity with habitual distance correction was assessed. A 10-item version of the PSS was administered in large print or by reading the items to the patient. Rasch analysis was used to investigate the measurement properties of the PSS, including fit to the model, ability to separate between people with different levels of perceived stress, category response structure performance, and unidimensionality.

RESULTS

A total of 137 patients with a diagnosis of AMD were enrolled. The mean (±SD) age of participants was 82 ± 9 years. Fifty-four percent were female. Median Early Treatment of Diabetic Retinopathy Study (ETDRS) visual acuity of the better eye was 65 letters (Snellen 20/50), with a range of approximately 20/800 to 20/15. Forty-seven percent of participants were receiving an anti-VEGF injection on the day of the study visit. The response category structure was appropriate. One item, "How often have you felt confident in your ability to handle your personal problems?" was removed due to poor fit statistics. The remaining nine items showed good fit to the model, acceptable measurement precision as assessed by the Rasch person separation statistic, and unidimensionality. There was some evidence of differential item functioning by age and visual acuity.

CONCLUSIONS

The Perceived Stress Scale demonstrated acceptable measurement properties and may be useful for the measurement of perceived stress in patients with AMD.

Coping experience of health concerns and physical disability for older Chinese people: A qualitative, descriptive study

In this qualitative, descriptive study, we explored the perspectives of older, community-dwelling Chinese people regarding their experiences of coping with a physical disability and their health concerns. Twenty participants were interviewed in-depth, and data were analyzed using content analysis. Five themes with 13 subthemes emerged that described older people's experiences of coping with health concerns and disability: (i) ignoring health concerns; (ii) managing self; (iii) seeking medical help; (iv) living with physical disability; and (v) relying on limited resources. Most participants did not have sufficient access to health services due to physical disability and financial deficits, so they tended to ignore their health conditions or tackle them independently before seeking medical help. At the same time, they were impacted on by social and cultural factors. Policies are required that offer more resources to community-dwelling people with disabilities in China.

AGE-RELATED MACULAR DEGENERATION AND THE RISK OF ALL-CAUSE AND CARDIOVASCULAR MORTALITY: A Meta-Analysis of Cohort Studies

PURPOSE

We evaluated the association between age-related macular degeneration (AMD) and the risk of all-cause and cardiovascular mortality by meta-analyses of data from prospective studies.

METHODS

A literature search was performed in PubMed, Web of Science, Embase, Cocharne Library, and China National Knowledge Infrastructure for relevant articles published up to December 2016. We estimated hazard ratios with 95% confidence intervals with fixed-effect models and conducted meta-regression to explore the potential sources of heterogeneity. Small-study effect was estimated by Egger's test and funnel plot.

RESULTS

We identified 13 population-based prospective cohort studies that examined the relationship between AMD and all-cause and cardiovascular mortality. Overall, the hazard ratios (95% confidence intervals) of all-cause mortality and cardiovascular mortality associated with any AMD were 1.15 (1.05-1.27) and 1.05 (95% confidence intervals: 0.87-1.26), respectively. The risk of all-cause mortality and cardiovascular mortality associated with early AMD were 1.08 (1.00-1.18) and 1.05 (0.89-1.24), and the associations with late AMD were 1.23 (1.11-1.36) and 1.28 (1.04-1.57), respectively. No evidence of small-study effect was found.

CONCLUSION

This meta-analysis indicated that AMD, especially late AMD, was associated with increased risk of all-cause mortality and cardiovascular mortality based on comparisons with people who did not have AMD and who were of similar age and sex.

The incidence and predictors of depressive and anxiety symptoms in older adults with vision impairment: a longitudinal prospective cohort study

PURPOSE

Depression and anxiety are highly prevalent in older adults with vision impairment. Because symptoms of depression and anxiety appear to fluctuate, it is important to identify patients who are at risk of developing these symptoms for early diagnosis and treatment. Therefore, the aim of this study was to determine the incidence of subthreshold depression and anxiety, and to investigate predictors of developing symptoms of depression and anxiety in older adults with vision impairment who had no subthreshold depression or anxiety at baseline.

METHODS

A longitudinal prospective cohort study with a follow-up of 24 months in 540 older adults with vision impairment (mean age 75 years, 56% female, 48% macular degeneration, 15% glaucoma) from outpatient low-vision rehabilitation organisations was performed. The cumulative incidences of subthreshold depression and anxiety were calculated and linear mixed models with maximum likelihood estimation were used to determine two prediction models. Main outcome measures were: fluctuations in (i) depressive symptoms (Center for Epidemiologic Studies Depression Scale, CES-D) and (ii) anxiety symptoms (Hospital Anxiety and Depression Scale-Anxiety subscale, HADS-A).

RESULTS

The annual cumulative incidences of subthreshold depression and anxiety were 21.3% (95% Confidence Interval (CI) 18.7-23.9%) and 9.5% (95% CI 7.4-11.6%), respectively. Risk factors for developing depressive symptoms were: living alone, having just enough money to cover expenses, having macular degeneration, having problems with adaptation to vision loss, reduced health related quality of life, and experiencing symptoms of anxiety. For developing anxiety symptoms, a relatively younger age, experiencing symptoms of depression, not living alone and experiencing hindrance at work proved to be risk factors.

CONCLUSIONS

This study shows that the incidence of subthreshold depression and anxiety in older adults with vision impairment is twice as high compared with older adults in general and confirms that depression and anxiety symptoms fluctuate over time. It is of great importance that low vision rehabilitation staff monitor older adults with vision impairment who are most vulnerable for developing these symptoms, based on the risk factors that were found in this study, to be able to offer early interventions to prevent and treat mental health problems in this population.

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

PURPOSE

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

DESIGN

Observational cross-sectional mixed-methods study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Estimation of depression prevalence in patients with Stargardt disease using PHQ-9 and Zung scores

PURPOSE

To evaluate the psychological impact and depression prevalence in patients with Stargardt disease.

METHODS

We conducted a case-control study including 39 patients with Stargardt disease and 32 age- and sex-matched healthy controls. All participants underwent a complete ophthalmologic examination and completed the Patient Health Questionnaire-9 (PHQ-9) and the Zung Depression Inventory questionnaire. Results were analyzed using IBM SPSS 22.0 software.

RESULTS

The patient group consisted of 19 men and 20 women with mean age of 36.9 ± 5.4 years and control group of 19 men and 13 women with mean age of 42.5 ± 10.1 years. The mean values of PHQ-9 and Zung scores for patients and healthy individuals were 10.9 ± 4.9, 46.7 ± 11.1, 6.7 ± 5.4, and 41.1 ± 8.5, respectively. There were statistically significant differences between the 2 groups in PHQ-9 scores (independent samples t test: p = 0.001), but not in Zung scores (Mann-Whitney test: p = 0.053). The PHQ-9 and Zung scores appeared to be moderately but significantly correlated (Pearson coefficient 0.44, p&lt;0.0001). In addition, PHQ-9 score seems to be raised along with age, whereas both scores are low when best-corrected visual acuity is high.

CONCLUSIONS

Patients with Stargardt disease exhibited more depressive symptoms compared to healthy individuals according mainly to PHQ-9 scores. Moderate depression was significantly correlated visual function decline.

Understanding the patient's lived experience of neovascular age-related macular degeneration: a qualitative study

PURPOSE

In industrialised populations age-related macular degeneration (ARMD) is the leading cause of visual disability of the elderly. Successful new treatment with anti-endothelial growth factors for neovascular-classified ARMD has led to a divergence in treatment and experiences of people ARMD. This study aimed to understand the participant's experience of neovascular ARMD, including ongoing treatment with anti-vascular endothelial growth factor.

METHODS

Twenty-five participants from one clinical site were qualitatively interviewed to elicit their experiences of treatment for neovascular ARMD.

RESULTS

Two major themes were identified. A life negotiated by neovascular ARMD captures the participants' experience of living with the condition and treatment regime for neovascular ARMD. The second major theme: Uncertainty displayed their appraisal of life, treatment and their perceived future.

CONCLUSIONS

Anxieties concerning the injections, new limitations to lifestyles, and an uncertain future all emerged from the data analysis. However, thankfulness for the treatment, the importance of familiar patterns in treatments and recovery and a guarded optimism also emerged. Knowledge of the experiences, anxieties and concerns of this patient population can be used to inform clinical practice and lead to patient-centred care.

Self-Rated Health, Cognition, and Dual Sensory Impairment Are Important Predictors of Depression Among Home Care Clients in Ontario

Depression can be a disabling and debilitating condition among older adults (aged 65+). This study examined risk factors for symptoms of depression in a large sample of older home care clients ( n = 218,850) in Ontario, Canada, using existing data collected with the Resident Assessment Instrument for Home Care (RAI-HC). The RAI-HC has been mandated across the province since 2002. The most important predictors of depression were lower self-rated health (odds ratio [OR] = 3.4), cognitive impairment (OR = 2.9), dual sensory impairment (OR = 1.2), and a primary language other than English or French (OR = 1.5). This suggests that not only physical health but also sensory impairments and communication difficulties increase the risk for depression among home care recipients.

Watchful waiting for subthreshold depression and anxiety in visually impaired older adults

Purpose

Immediate treatment of depression and anxiety may not always be necessary in resilient patients. This study aimed to determine remission rates of subthreshold depression and anxiety, incidence rates of major depressive and anxiety disorders, and predictors of these remission and incidence rates in visually impaired older adults after a three-month ‘watchful waiting’ period.

Methods

A pretest–posttest study in 265 visually impaired older adults (mean age 74 years), from outpatient low-vision rehabilitation services, with subthreshold depression and/or anxiety was performed as part of a randomised controlled trial on the cost-effectiveness of a stepped-care intervention. An ordinal logistic regression analysis was conducted. Main outcome measures were: (1) subthreshold depression and anxiety measured with the Centre for Epidemiologic Studies Depression Scale (CES-D) and the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A), and (2) depressive and anxiety disorders measured with the Mini International Neuropsychiatric Interview.

Results

After a three-month watchful waiting period, depression and anxiety decreased significantly by 3.8 (CES-D) and 1.4 points (HADS-A) (p < 0.001). Of all participants, 34 % recovered from subthreshold depression and/or anxiety and 18 % developed a depressive and/or anxiety disorder. Female gender [odds ratio (OR) 0.49, 95 % confidence interval (CI) 0.28–0.86], more problems with adjustment to vision loss at baseline (OR 1.02, 95 % CI 1.00–1.03), more symptoms of depression and anxiety at baseline (OR 1.06, 95 % CI 1.02–1.10), and a history of major depressive, dysthymic, and/or panic disorder (OR 2.28, 95 % CI 1.28–4.07) were associated with lower odds of remitting from subthreshold depression and/or anxiety and higher odds of developing a disorder after watchful waiting.

Conclusions

Watchful waiting can be an appropriate step in managing depression and anxiety in visually impaired older adults. However, female gender, problems with adjustment to vision loss, higher depression and anxiety symptoms, and a history of a depressive or anxiety disorder confer a disadvantage. Screening tools may be used to identify patients with these characteristics, who may benefit more from higher intensity treatment or a shorter period of watchful waiting.

Rasch validation of the PHQ-9 in people with visual impairment in South India

BACKGROUND

The Patient-Health Questionnaire (PHQ-9) is a widely used screening instrument for depression. Recently, its properties as a measure were investigated using Rasch analysis in an Australian population with visual impairment (VI) and it was demonstrated to possess excellent measurement properties, but the response scale required shortening (modified PHQ-9). However, further validation was recommended to substantiate its use with the growing population of VI. Therefore, we aimed to use Rasch analysis to evaluate the measurement properties of the modified PHQ-9 in an Indian population with VI.

METHODS

303 patients with VI (mean age 40.2 years; 71% male) referred to Vision Rehabilitation Centres were administered the PHQ-9 by trained interviewer. Rasch analysis was used to investigate the psychometric properties of the modified PHQ-9.

RESULTS

Rasch analysis showed good fit to the model, no misfitting items and an acceptable person separation reliability (0.82). Dimensionality testing supported combining 9 items to create a total score. Targeting was sub-optimal (-1.30 logits); more difficult items are needed. One item ('trouble falling asleep') showed notable differential item functioning, DIF (1.18 logits) by duration of VI.

LIMITATIONS

The generalisability of these results might be restricted to patients with VI presenting to a tertiary eye care centre.

CONCLUSIONS

Except for DIF, the performance of the modified PHQ-9 is consistent with that of the original, albeit in a different cultural context (Indian population with VI). Clinicians/researchers can readily use the modified PHQ-9 without formal training in Rasch procedures given the provision of ready-to-use spreadsheets that convert raw to Rasch-scaled scores. However the conversions will apply only if the sample being tested is similar to that of the present study.

Age-related macular degeneration and mortality in older women: the study of osteoporotic fractures

OBJECTIVES

To examine the association between age-related macular degeneration (AMD) and all-cause and cause-specific mortality in a population of older women.

DESIGN

Prospective cohort study.

SETTING

Four U.S. clinical centers.

PARTICIPANTS

A random sample of 1,202 women with graded fundus photographs at the Year 10 visit of the Study of Osteoporotic Fractures (mean age 79.5).

MEASUREMENTS

Forty-five-degree stereoscopic fundus photographs were graded for presence and severity (early vs late) of AMD. Vital status was adjudicated from death certificates. Cox proportional hazards models, adjusted for appropriate confounders, were used to estimate mortality hazards ratios.

RESULTS

Prevalence of any AMD was 40.5% at baseline, with 441 (36.7%) having early AMD and 46 (3.8%) having late AMD. Cumulative mortality was 51.6% over 15 years of follow-up. Overall, there was no significant association between AMD presence or severity and all-cause or cause-specific mortality. Because there was a significant interaction between AMD and age in predicting mortality (P<.05 for each mortality type), analyses were stratified according to age group. In women younger than 80, after adjusting for covariates, late AMD was associated with cardiovascular disease (CVD) mortality (hazard ratio (HR)=2.61, 95% confidence interval (CI)=1.05-6.46). In women aged 80 and older, early AMD was associated with all-cause (HR=1.39, 95% CI=1.11-1.75) and non-CVD, noncancer (HR=1.45, 95% CI=1.05-2.00) mortality. Any AMD was associated with all-cause (HR=1.42, 95% CI=1.13-1.78) and CVD (HR=1.45, 95% CI=1.01-2.09) mortality in women aged 80 and older.

CONCLUSION

AMD is a predictor of poorer survival in women, especially those aged 80 and older. Determination of shared risk factors may identify novel pathways for intervention that may reduce the risk of both conditions.

Why visually impaired older adults often do not receive mental health services: the patient's perspective

PURPOSE

Older adults with a visual impairment are particularly vulnerable for increased depression and anxiety symptoms; however, they tend to underutilise mental health services. The present study aims to characterise the perceived need for and barriers to use mental health services in visually impaired older adults based on Andersen's behavioural model.

METHODS

A cross-sectional study in 871 visually impaired older adults (mean age 73 years) from outpatient low vision rehabilitation services was conducted. A multinomial logistic regression analysis was performed to assess potential-related factors to perceived need for mental health services, measured with the Perceived Need for Care Questionnaire (PNCQ).

RESULTS

About 35 % of the population had subthreshold depression and/or anxiety, and 13 % had a mood and/or anxiety disorder according to the DSM-IV. Almost 34 % of the participants with an actual disorder did not receive mental health services, even though 57 % perceived to be in need of these services. Participants who had more severe depression and/or anxiety, comorbid depression and anxiety, no history of major depressive disorder, a lower perceived health status and a younger age were more likely to be in need of mental health services. Barriers to receive these services were lack of knowledge and self-reliance.

CONCLUSIONS

Findings support the implementation of counselling methods, instead of medication, and patient empowerment to reduce an unmet need of mental health services in visually impaired older adults, for which extensive research is warranted.

Personality and Functional Vision in Older Adults with Age-Related Macular Degeneration

Introduction

The purpose of the study was to determine whether personality traits influence self-reported functional vision in patients with age-related macular degeneration (AMD).

Methods

This is a prospective cross-sectional analysis of baseline data from the Low Vision Depression Prevention Trial. Participants ( N = 182) over age 65 with bilateral AMD, visual acuity worse than 20/70 in the better-seeing eye, and subthreshold depression were recruited from the Wills Eye Hospital retina practice. Assessments included visual acuity, contrast sensitivity, National Eye Institute Visual Function Questionnaire–25 plus Supplement (NEI VFQ–25) near and distance subscales, depression, and personality testing. Structural equation models were used to investigate the relationship of the NEI VFQ near activities and distance activities with the various demographic, clinical, and psychological predictors.

Results

In the single-predictor model for near functional vision, visual acuity at logMAR ≤ 1 (estimate = −0.33 [95% confidence interval {CI} −0.46, −0.20]; p ≤ 0.001), neuroticism (estimate = −0.05 [95% CI −0.08, −0.01]; p = 0.01), and education (estimate = −0.08 [95% CI 0.01, 0.15]; p = 0.03) were statistically significant predictors. In the single-predictor model for distance functional vision, only visual acuity at logMAR ≤ 1 (estimate = −0.49 [95% CI −0.69, −0.29]; p ≤ 0.001) and neuroticism (estimate = −0.09 [95% CI −0.15, 0.02]; p = 0.008) were statistically significant predictors. Discussion: Self-reported functional vision depends on the severity of vision loss as well as the personality trait of neuroticism.

Implications for practitioners

Assessment of personality traits, particularly neuroticism, may increase the precision of rating scales of functional vision and suggest new rehabilitative interventions to improve the functional vision and quality of life of patients with AMD.

Ranibizumab: a review of its use in the treatment of neovascular age-related macular degeneration

Ranibizumab (Lucentis(®)), an inhibitor of all vascular endothelial growth factor (VEGF) A isoforms, is approved for the intravitreal treatment of neovascular age-related macular degeneration (AMD). In pivotal trials, monthly injections of ranibizumab were superior to verteporfin photodynamic therapy in the treatment of predominantly classic choroidal neovascularization (CNV) due to neovascular AMD (ANCHOR) and sham in the treatment of minimally classic or occult CNV due to neovascular AMD (MARINA). Monthly or less frequent injections of ranibizumab are generally well tolerated and associated with low rates of ocular and systemic serious adverse events (SAEs). Less frequent dosing has been evaluated with the aim of reducing the burden, risk and cost of monthly injections. In the landmark CATT trial, monthly monitoring and retreatment as-needed with ranibizumab was equivalent to monthly treatment in terms of the vision gain at 1 year, but reduced the number of injections (and the related cost) by approximately one-half. In head-to-head comparisons, aflibercept administered bimonthly was noninferior to ranibizumab administered monthly (VIEW 1 and 2), bevacizumab administered monthly was equivalent to ranibizumab administered monthly (CATT), and bevacizumab administered as-needed was equivalent to ranibizumab administered as-needed (CATT). Bevacizumab is widely used (off-label) for economic reasons; while it was less costly than ranibizumab, it was associated with more systemic SAEs. Notwithstanding the availability of other similarly effective anti-VEGF therapies that are approved (aflibercept) or unapproved (bevacizumab), ranibizumab continues to set the standard as regards the totality of evidence from randomized clinical trials demonstrating its efficacy and tolerability (particularly that of the monthly regimen) in the treatment of neovascular AMD.

The psychological challenge of late-life vision impairment: concepts, findings, and practical implications

The intention is to summarize the body of evidence speaking to the psychological challenges faced by visually impaired older adults, as well as their coping efforts. This evidence is substantiated by a rich set of concepts, theories, and empirical findings that have accumulated under the umbrella of age-related psychoophthalmology (APO). I introduce the field of APO and continue with a discussion of important concepts and theories for a better understanding of adaptational processes in visually impaired older adults. I then summarize the most relevant and most recent data from four areas: (1) everyday competence, (2) cognitive functioning, (3) social functioning, and (4) subjective well-being-related outcomes, depression, and adaptational processes. Thereafter, major insights related to the current state-of-the art psychosocial interventions with visuallyimpaired older adults are reviewed. I close with the need that the public health community should become more aware of and address the psychosocial needs of visually impaired older adults.

Tango programme for individuals with age-related macular degeneration

Recent research shows that tango dance is an absorbing and effective strategy to reduce levels of depression, while also increasing well-being. This study investigates the feasibility, acceptability, and adherence to a tango programme for individuals with age-related macular degeneration (ARMD). Depression is closely intertwined with the ARMD diagnosis, since the loss of central vision has a profoundly negative impact on the person’s quality of life. Seventeen participants were randomised to tango dance (1.5 h, 2 times/week for 4 weeks) or wait-list control condition. Demographic questions and Visual Function Questionnaire were taken at pre-test. Self-rated symptoms of depression, self-esteem, and satisfaction-with-life were assessed at pre-test and post-test. Tango group participants showed significant reductions in depression and significantly increased satisfaction-with-life and self-esteem at post-test relative to the controls, and reported physical improvement, including increased balance. Tango dance was demonstrated to be a feasible and positive activity for this population.

Improving balance and mobility in people over 50 years of age with vision impairments: can the Alexander Technique help? A study protocol for the VISIBILITY randomised controlled trial

BACKGROUND

Falls are an increasingly important and costly public health problem. Vision is key to postural stability as we age and this puts adults with visual impairments at greater risk of falls. Physical interventions improve balance in the general population and in older adults with visual impairments in residential care. They also prevent falls in the general community but to date have not been shown effective in community-dwelling adults with visual impairments.

OBJECTIVE

To investigate, with a randomised controlled trial, whether the Alexander Technique (AT) can improve balance and mobility in the community-dwelling population with visual impairments and thus reduce the risk of falls. The AT is a form of physical re-education that has recently received attention for its possible value in rehabilitation.

METHOD AND DESIGN

One hundred and twenty people with visual impairments over 50 years of age will be recruited from Guide Dogs New South Wales/Australian Capital Territory (NSW/ACT). Participants will be independently mobile and cognitively able to take part in the programme. After baseline assessment participants will be randomly assigned to two groups. The control group will receive usual care from Guide Dogs NSW/ACT, and the intervention group will receive 12 weekly home-based lessons in the AT in addition to usual care. The primary outcome measures will be physical measures from the short physical performance battery at 3 months. Secondary outcome measures will be balance, mobility, social participation and emotional well-being at 3 and 12 months.

TRIAL REGISTRATION NUMBER

The protocol is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12610000634077).

[Depression in Patients with Age-Related Macular Degeneration]

Age-related macular degeneration is a cause for disability in the elderly since it greatly affects their quality of life and increases depression likelihood. This article discusses the negative effect depression has on patients with age-related macular degeneration and summarizes the interventions available for decreasing their depression index.

Poor vision, functioning, and depressive symptoms: a test of the activity restriction model

PURPOSE

This study tested the applicability of the activity restriction model of depressed affect to the context of poor vision in late life. This model hypothesizes that late-life stressors contribute to poorer mental health not only directly but also indirectly by restricting routine everyday functioning.

METHOD

We used data from a national probability-based sample of older adults (N = 1,178; M = 69.2 years, approximately 50% female). Vision was assessed both subjectively (via self-report) and objectively (via a visual acuity test). Respondents also reported on their levels of physical and driving limitations, feelings of social isolation, and symptoms of depression.

RESULTS

Path analyses indicated a strong fit of the data to the activity restriction model for subjective vision. In addition to directly contributing to higher depressive symptomatology, subjective vision contributed to depressive symptoms indirectly by predicting more physical limitations and feelings of social isolation that, in turn, contributed to more symptoms of depression; driving limitations did not mediate the relationship between subjective vision and depressive symptomatology. Objective vision contributed significantly to physical and driving limitations but was unrelated to feelings of social isolation and depressive symptomatology. 

IMPLICATIONS

Supporting the activity restriction model, poorer self-rated vision in late life contributes to lower mental health directly and also indirectly by restricting individuals' ability to carry out routine day-to-day physical activities and increasing their feelings of social isolation. Interventions for older adults with vision-related problems could focus on maintaining or enhancing their physical and social functioning in order to promote their adaptation to poor vision.

Depression training program for eye health and rehabilitation professionals

PURPOSE

Depression often remains undetected in people with vision impairment. This study aimed to determine the effectiveness of a depression training program on practitioners' confidence, perceived barriers, and their likelihood of responding to depression in patients with vision impairment.

METHODS

This study was a pre and post single group evaluation involving 36 eye health and rehabilitation practitioners. Three 1.5-h group training sessions were held once a week for 3 consecutive weeks. The modules covered (1) understanding depression, (2) detecting depressive symptoms, and (3) developing and implementing referral pathways. Three main outcome measures were assessed: confidence in working with patients who may be depressed; perceived barriers to the recognition and management of depression; and likelihood of responding to depression.

RESULTS

The training significantly improved practitioners' confidence and reduced perceived barriers to managing depression (p < 0.001). After training, participants were significantly more likely to respond to depression in their patients (p < 0.001).

CONCLUSIONS

This preliminary study found that a brief training program is effective in increasing practitioners' ability to respond to depression in patients with vision impairment. Further work is required to determine whether these effects are sustained over time and result in improved recognition and management of depression in people with vision impairment.

Profile of Personnel Preparation Programs in Visual Impairment and Their Faculty

This survey of university personnel preparation programs in visual impairment in the United States and Canada investigated the demographic characteristics of faculty members and programs, instructional models, and funding formulas in 2007–08. It found that many programs used some form of distance education and that there was a correlation between tenure status and the age of the program. Trends for this and the previous four surveys are examined.