Diagnostic accuracy of community optometrists for age-related macular degeneration using colour fundus photographs: A pilot evaluation

PURPOSE

The accurate diagnosis of age-related macular degeneration (AMD) represents an important step in delaying and preventing vision loss and achieving optimal patient care. Therefore, this pilot study aimed to estimate the diagnostic accuracy of community optometrists for identifying AMD using colour fundus photographs (CFPs) to support sample size calculations for subsequent definitive studies.

METHODS

Five practising community optometrists were invited to classify a total of 1023 CFPs for the (1) presence of AMD, and, if applicable, (2) stage of AMD (early/intermediate/late geographic atrophy/late neovascular AMD). Diagnosis by referral centre clinicians formed the reference standard. Diagnostic accuracy was assessed by the area under the receiver operating characteristic curve (aROC). Sensitivity, specificity, positive and negative predictive values were also calculated.

RESULTS

Of the 1023 CFPs included in the study, 226 images were of AMD and 797 images were of other ocular conditions or no abnormal findings. Participating community optometrists had a mean (SD) age of 30.2 (8.9) years, 60.0% (3/5) were female and the mean number of years practising in primary eye care was 5.4 (5.4) years. Community optometrists demonstrated excellent performance for diagnosing AMD, with an aROC of 0.86 (95% CI 0.83 to 0.89), sensitivity of 84.5% (95% CI 79.1 to 89.0) and specificity of 88.0% (95% CI 85.5 to 90.1). The aROC (95% CI) for diagnosing early, intermediate, late geographic atrophy and late neovascular AMD was 0.82 (0.73 to 0.91), 0.76 (0.72 to 0.81), 0.69 (0.49 to 0.90) and 0.55 (0.34 to 0.75), respectively.

CONCLUSIONS

These results justify the need for an appropriately powered definitive study to assess community clinicians' diagnostic accuracy for AMD.

OCT Prognostic Biomarkers for Progression to Late Age-related Macular Degeneration: A Systematic Review and Meta-analysis

TOPIC

To evaluate which OCT prognostic biomarkers best predict the risk of progression from early/intermediate to late age-related macular degeneration (AMD).

CLINICAL RELEVANCE

Among > 100 OCT prognostic biomarkers for AMD, it is unclear which are the most relevant for clinicians and researchers to focus on. This review evaluated which OCT biomarkers confer the greatest magnitude of prediction for progression to late AMD.

METHODS

Study protocol was registered on PROSPERO (CRD42023400166). PubMed and Embase were searched from inception to March 2, 2023, and eligible studies assessed following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The primary outcome was any quantified risk of progression from treatment-naive early/intermediate AMD to late AMD, including hazard ratios (HRs), odds ratios (ORs), and standardized mean differences (at baseline, between eyes with versus without progression), subgrouped by each OCT biomarker. Further meta-analyses were subgrouped by progression to geographic atrophy or neovascularization.

RESULTS

A total of 114 quantified OCT prognostic biomarkers were identified. With high GRADE certainty of evidence, the greatest magnitudes of prediction to late AMD belonged to: external limiting membrane abnormality (OR, 15.42 [7.63, 31.17]), ellipsoid zone abnormality (OR, 10.8 [4.58, 25.46]), interdigitation zone abnormality (OR, 7.68 [2.57, 23]), concurrent large drusen and reticular pseudodrusen (HR, 6.73 [1.35, 33.65], hyporeflective drusen cores (HR, 2.48 [1.8, 3.4]; OR 1.85 [1.29, 2.66]), intraretinal hyperreflective foci (IHRF; HR, 2.16 [0.92, 5.07]; OR 5.08 [3.26, 7.92]), and large drusen (HR, 2.01 [1.35, 2.99]); OR, 1.98 [1.27, 3.08]). There was greater risk of geographic atrophy for IHRF and hyporeflective drusen cores (P < 0.05), and neovascularization for ellipsoid zone abnormality (P < 0.05). Other OCT biomarkers such as drusenoid pigment epithelium detachment, shallow irregular retinal pigment epithelium elevations, and nascent geographic atrophy exhibited large magnitudes of risk but required further studies for validation.

CONCLUSION

This review synthesizes the 6 most relevant OCT prognostic biomarkers for AMD with greater predictive ability than large drusen alone, for clinicians and researchers to focus on. Further study is required to validate other biomarkers with less than high certainty of evidence, and assess how the copresence of biomarkers may affect risks.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Evaluating the clinical relevance and reliability of outer retinal band length on optical coherence tomography in retinal disease: a cross-sectional study

OBJECTIVES

Hyper-reflective outer retinal band (HORB) disruptions are reported across a range of retinal disease, yet a reliable, easily implemented assessment method and thorough evaluation of their association to retinal disease is lacking. The purpose of the study was to assess the reliability of using magnitude estimation to evaluate HORB length and determine its association to visual acuity and retinal disease.

DESIGN

Cross-sectional, retrospective study.

SETTING

Patients attending a secondary eye care clinic in Sydney, Australia.

PARTICIPANTS

2039 unique consecutive patients were screened for inclusion between 2 November and 18 January 2021, and 600 were included in the study population. Patients were included if they were referred from primary care, presented for an initial, comprehensive eye examination during the study period, imaged with optical coherence tomography during their visit and over 18 years of age.

PRIMARY OUTCOME

Reliability of HORB length estimations and associations to clinical outcomes.

RESULTS

Intragrader (intraclass correlation coefficient, ICCfovea=0.81; ICCworst=0.91) and intergrader (ICCfovea=0.78-0.79; ICCworst=0.75-0.88) agreement of HORB length was good to excellent. HORB length was significantly associated with age (p<0.001, β=-0.22 to -0.24) and refractive error (p<0.001, β=0.12-0.16) at all B-scan locations. Visual acuity (p=0.001, β=-0.13) was associated with the primary outcome for foveal B-scans and eccentricity (p=0.002, β=-0.13) and device type (p=0.002, β=0.13) for non-foveal B-scans. Glaucoma was associated with HORB length on univariate analysis (p=0.05-0.06, β=-0.08); however, multivariate analysis revealed no significant association between HORB length and retinal disease.

CONCLUSION

HORB length is reliably assessed using magnitude estimation and may be useful as a surrogate biomarker of visual acuity. Several factors affect HORB length estimations, which may contribute to the lack of association to retinal disease and highlights the need for covariable adjustment when examining HORB disruptions.

Effective health communication for age-related macular degeneration: An exploratory qualitative study

PURPOSE

Age-related macular degeneration (AMD) is a major cause of vision loss globally. Patients with AMD may not always understand or retain the information about AMD communicated by their eyecare practitioner. This study aims to explore the characteristics of effective health communication for AMD, from both patients' and eyecare practitioners' perspectives. The purpose is to provide a foundation for understanding how health communication for AMD could potentially be improved in the future.

METHODS

A total of 10 focus groups involving 17 patients with AMD and 17 optometrists were conducted via web conferencing. Each session was audio-recorded, transcribed and analysed using the Grounded Theory Methodology.

RESULTS

The five themes identified are as follows: (1) materials' quality, (2) materials' relevance, (3) contextualising for the individual, (4) contextualising for the disease and (5) support network. Participants expressed concern about the unrealistic yet common depiction of vision loss in AMD as a black patch overlying common visual scenes. They also preferred education materials tailored to a specific disease stage and the regular opportunity to ask or answer questions. Longer appointment durations and peer support (from family, friends or others with AMD) were also valued.

CONCLUSION

Optometrists are encouraged to focus on three over-arching dimensions when counselling patients with AMD in routine clinical practice: (1) curating and using disease and stage-specific, impactful education materials, (2) their chairside verbal communication techniques and (3) AMD-specific opportunities for care coordination among patient family and friends, peers and other multidisciplinary members of the care support team.

Drusen-aware model for age-related macular degeneration recognition

INTRODUCTION

The purpose of this study was to build an automated age-related macular degeneration (AMD) colour fundus photography (CFP) recognition method that incorporates confounders (other ocular diseases) and normal age-related changes by using drusen masks for spatial feature supervision.

METHODS

A range of clinical sources were used to acquire 7588 CFPs. Contrast limited adaptive histogram equalisation was used for pre-processing. ResNet50 was used as the backbone network, and a spatial attention block was added to integrate prior knowledge of drusen features into the backbone. The evaluation metrics used were sensitivity, specificity and F1 score, which is the harmonic mean of precision and recall (sensitivity) and area under the receiver-operating characteristic (AUC). Fivefold cross-validation was performed, and the results compared with four other methods.

RESULTS

Excellent discrimination results were obtained with the algorithm. On the public dataset (n = 6565), the proposed method achieved a mean (SD) sensitivity of 0.54 (0.09), specificity of 0.99 (0.00), F1 score of 0.62 (0.06) and AUC of 0.92 (0.02). On the private dataset (n = 1023), the proposed method achieved a sensitivity of 0.92 (0.02), specificity of 0.98 (0.01), F1 score of 0.92 (0.01) and AUC of 0.98 (0.01).

CONCLUSION

The proposed drusen-aware model outperformed baseline and other vessel feature-based methods in F1 and AUC on the AMD/normal CFP classification task and achieved comparable results on datasets that included other diseases that often confound classification. The method also improved results when a five-category grading protocol was used, thereby reflecting discriminative ability of the algorithm within a real-life clinical setting.

Optometrists' attitudes toward using OCT angiography lag behind other retinal imaging types

PURPOSE

While optometrists' attitudes toward established retinal imaging types are generally positive, they are unknown for optical coherence tomography angiography (OCTA). We performed a cross-sectional survey to estimate attitudes toward OCTA and identify clinician and/or practice characteristics that influence them.

METHODS

A paper-based survey was mailed to 252 randomly selected optometrists in Australia. Five-point Likert-scale items from a previous survey assessing attitudes toward new technology were included to probe respondent characteristics and attitudes toward retinal imaging. Performance expectancy attitudes toward OCTA were elicited by the statement 'I believe OCTA is useful in daily practice'. Mean scores out of five (mean [SD]) were rounded and mapped to appropriate descriptive statements.

RESULTS

The response rate was 47% (118/252). The mean (SD) age of respondents was 44.0 (13.8) years and 50.8% (60/118) were female. Optometrists had 19.9 (14.0) years of clinical experience and 66.9% (79/118) worked at independent practices. In total, 8.5% (10/118) of respondents used OCTA to provide clinical care. Optometrists agreed that optical coherence tomography (OCT), colour fundus imaging, ultra-wide field imaging and fundus autofluorescence (mean scores 3.6-4.7 out of 5) were useful in daily practice but felt neutral about whether OCTA was useful (3.4 [0.8]). Optometrists believed that OCTA was less enjoyable to use (p < 0.0001), less endorsed by peers (p < 0.0001) and felt less confident that they had the knowledge to interpret OCTA (p < 0.0001) compared to other retinal imaging types.

CONCLUSIONS

Optometrists are undecided on whether OCTA is useful in daily practice and had lower expectations that using OCTA would confer job performance benefits compared to other retinal imaging types. Further work is needed to advocate the benefits of using OCTA across the profession.

Diagnostic accuracy of OCTA and OCT for myopic choroidal neovascularisation: a systematic review and meta-analysis

BACKGROUND/OBJECTIVES

The purpose of this project was to systematically review and meta-analyse studies assessing the diagnostic accuracy of optical coherence tomography angiography (OCTA) and optical coherence tomography (OCT) for myopic choroidal neovascularisation (mCNV). Fluorescein angiography (FA) was accepted as the reference standard.

METHODS

PUBMED and EMBASE were searched from inception to March 2021 for studies evaluating the test accuracy of OCTA and/or OCT for diagnosing mCNV. The Preferred Reporting Items for Systematic Reviews and Meta-analyses of Diagnostic Test Accuracy Studies guideline was followed, and the Grading of Recommendations, Assessment, Development and Evaluation approach was used to frame clinical recommendations. Pooled estimates of test accuracy were obtained using a bivariate model.

RESULTS

Of 410 studies assessed for eligibility, 3 studies were identified that compared OCTA to FA and 3 studies were identified that compared spectral domain (SD) OCT to FA. All studies had at least one major methodological flaw leading to an overall high risk of bias. On meta-analysis, the pooled sensitivity of OCTA was 0.89 (95% CI 0.78-0.94) and pooled specificity was 0.93 (95% CI 0.79-0.98). The pooled sensitivity of SD-OCT was 0.99 (95% CI 0.91-1.00). Due to uncertainty in individual studies, the pooled specificity of SD-OCT could not be estimated.

CONCLUSIONS

OCTA can reliably diagnose mCNV in clinically suspected patients, however, SD-OCT may not reliably establish a positive diagnosis of mCNV. Future large, prospective studies with improvements in conduct and reporting are needed to strengthen these clinical recommendations.

Attitudes of optometrists towards artificial intelligence for the diagnosis of retinal disease: A cross-sectional mail-out survey

PURPOSE

Artificial intelligence (AI)-based systems have demonstrated great potential in improving the diagnostic accuracy of retinal disease but are yet to achieve widespread acceptance in routine clinical practice. Clinician attitudes are known to influence implementation. Therefore, this study aimed to identify optometrists' attitudes towards the use of AI to assist in diagnosing retinal disease.

METHODS

A paper-based survey was designed to assess general attitudes towards AI in diagnosing retinal disease and motivators/barriers for future use. Two clinical scenarios for using AI were evaluated: (1) at the point of care to obtain a diagnostic recommendation, versus (2) after the consultation to provide a second opinion. Relationships between participant characteristics and attitudes towards AI were explored. The survey was mailed to 252 randomly selected practising optometrists across Australia, with repeat mail-outs to non-respondents.

RESULTS

The response rate was 53% (133/252). Respondents' mean (SD) age was 42.7 (13.3) years, and 44.4% (59/133) identified as female, whilst 1.5% (2/133) identified as gender diverse. The mean number of years practising in primary eye care was 18.8 (13.2) years with 64.7% (86/133) working in an independently owned practice. On average, responding optometrists reported positive attitudes (mean score 4.0 out of 5, SD 0.8) towards using AI as a tool to aid the diagnosis of retinal disease, and would be more likely to use AI if it is proven to increase patient access to healthcare (mean score 4.4 out of 5, SD 0.6). Furthermore, optometrists expressed a statistically significant preference for using AI after the consultation to provide a second opinion rather than during the consultation, at the point-of-care (+0.12, p = 0.01).

CONCLUSIONS

Optometrists have positive attitudes towards the future use of AI as an aid to diagnose retinal disease. Understanding clinician attitudes and preferences for using AI may help maximise its clinical potential and ensure its successful translation into practice.

Multispectral pattern recognition measures change in drusen area in age-related macular degeneration with high congruency to expert graders

Drusen are a hallmark lesion of age-related macular degeneration (AMD) and changes in their area and/or volume are strongly associated with disease progression. Assessment of longitudinal change in drusen size in clinical practice however is limited to a single commercial tool or manual inspection by clinicians. In this study we analysed change in drusen area in 33 eyes with intermediate AMD across two separate visits using a novel technique known as multispectral pattern recognition for en face retinal images from various imaging modalities (infrared (815 nm), fundus autofluorescence (488 nm) and green (532 nm) scanning laser ophthalmoscopy). We found 91% (30/33 eyes) agreement in the direction of drusen change for multispectral pattern recognition relative to expert graders who graded eyes as having drusen progression, regression or being stable. Multispectral pattern recognition showed 100% sensitivity (22/22 eyes) and 73% specificity (8/11 eyes). In comparison, we found only 70% (23/33 eyes) agreement in the direction of drusen change with a commercially available change analysis software, the Cirrus Advanced RPE Analysis relative to expert graders, with a sensitivity 64% (14/22 eyes) and specificity of 82% (9/11 eyes). Total drusen area or amount of change between visits had no significant effect on agreement. This suggests multispectral pattern recognition can quantify longitudinal change in drusen area from multimodal imaging with greater congruency to expert graders than a commercially available platform based on a single imaging modality. Considering the association of drusen area and disease progression, this method could aid clinical assessment and monitoring of AMD.

Assessment of patient education materials for age-related macular degeneration

Purpose

Age‐related macular degeneration (AMD) is a leading cause of vision loss. It is helpful for patients living with AMD to understand the prognosis, risk factors and management of their condition. Online education materials are a popular and promising channel for conveying this knowledge to patients with AMD. However, the quality of these materials—particularly with respect to qualities such as ‘understandability’ and ‘actionability’—is not yet known. This study assessed a collection of online materials about AMD based on these qualities of ‘understandability’ and ‘actionability’.

Methods

Online education materials about AMD were sourced through Google from six English‐speaking nations: Australia, New Zealand, USA, UK, Ireland and Canada. Three Australian/New Zealand trained and registered optometrists participated in the grading of the ‘understandability’ and ‘actionability’ of online education materials using the Patient Education Materials Assessment Tool (PEMAT).

Results

This study analysed a total of 75 online materials. The mean ‘understandability’ score was 74% (range: 38%–94%). The ‘understandability’ PEMAT criterion U11 (calling for a summary of the key points) scored most poorly across all materials. The mean ‘actionability’ score was 49% (range: 0%–83%). The ‘actionability’ PEMAT criterion A26 (using ‘visual aids’ to make instructions easier to act on) scored most poorly across all materials.

Conclusion

Most education materials about AMD are easy to understand, but difficult to act on, because of a lack of meaningful visual aids. We propose future enhancements to AMD education materials—including the use of summaries, visual aids and a habit tracker—to help patients with AMD improve their understanding of disease prognosis, risk factors and eye assessment schedule requirements.

Clinical decision support in primary care for better diagnosis and management of retinal disease

Misdiagnosis of retinal disease is a common problem in primary care that can lead to irreversible vision loss and false-positive referrals, resulting in inappropriate use of health services. Clinical decision support systems describe tools that leverage information technology to provide timely recommendations that assist clinicians in the decisions they make about the care of a patient. They, therefore, have the potential to reduce the rate of misdiagnosis by promoting evidence-based medicine and more effective and efficient healthcare. This narrative review aims to support primary care practitioners in better understanding the current and emerging capacity of clinical decision support systems in eye care. Different types of clinical decision support systems are discussed, using current examples and evidence from the available literature to demonstrate how they may improve diagnostic effectiveness and aid the management of retinal disease. Comments are made on the future directions of clinical decision support in primary eye care and the potential applications of artificial intelligence.

Ocular ischaemia: signs, symptoms, and clinical considerations for primary eye care practitioners

Ischaemic stroke is a major disease burden as well as a leading cause of death. Early signs of ischaemic stroke can manifest in the eye, placing primary eyecare practitioners in an important position to identify patients at risk of ischaemic stroke and initiate suitable referral pathways. The vascular supply to the brain is reviewed with reference to vision including the various retinal signs and ocular symptoms associated with transient ischaemic attacks and ischaemic stroke. Using a range of clinical cases, the diverse clinical presentations of retinal embolic events, as well as other forms of vascular occlusion, are highlighted and the underlying pathophysiology is discussed. A succinct scheme for the assessment and management of ischaemic events for primary eye care practitioners is provided.

Examining the neural correlates of goal priming with the NeuroShop, a novel virtual reality fMRI paradigm

OBJECTIVE

Health goal priming has been shown to stimulate healthy food choices by activating an individual's weight-control goal. The present study combined fMRI with a novel virtual reality food choice task to elucidate the underlying neural mechanisms of health goal priming. Previous research has suggested that the ventromedial prefrontal cortex (vmPFC) and dorsolateral prefrontal cortex (dlPFC) play a role in the incorporation of health considerations into the food choice process. Responses may be more representative for those found in real life when assessed in an environment similar to the actual choice environment. Therefore, the first aim of the study was to explore if a novel virtual reality food choice task is sufficiently sensitive to detect basic valuation processes in food choice. The second aim was to examine whether increased activation in the dlPFC drives the effects of health goal priming.

METHODS

Fifty-six female participants performed an fMRI food choice task embedded in a virtual supermarket environment. They chose between perceived healthy and unhealthy products in a health prime, hedonic prime, and non-food control condition, while activation in brain areas involved in self-control and valuation (vmPFC, dlPFC) was assessed.

RESULTS

There were no differences in relative preference for perceived healthy products over unhealthy products between the conditions. There were also no main effects of prime condition on brain activation in the vmPFC and dPFC during food choice. Across conditions, activation in the vmPFC correlated with the tastiness of the chosen product during food choice.

CONCLUSIONS

Although the study does not provide support for health goal priming triggering neural self-control mechanisms, results did show that virtual reality has potential for a more realistic fMRI food choice paradigm.

Introduction of structured record keeping in age-related macular degeneration: a before and after study

CLINICAL RELEVANCE

Structured record keeping improves documentation in age-related macular degeneration; however, it may have a more limited effect on the management decisions of a group of already highly trained clinicians, especially in the context of other well-embedded clinical decision support tools.

BACKGROUND

Structured record keeping has been associated with a range of advantages including improved history taking and communication, reduced number of unnecessary referrals, and enhanced diagnostic accuracy. The aim of this study was to examine the impact of a structured record keeping, quality improvement tool on recording, reporting and management congruency.

METHODS

A before and after retrospective record review study was performed in a single academic, intermediate-tier care institute in New South Wales, Australia. The structured record keeping tool intervention captured 31 items in addition to the prior pre-existing medical record: six items relating to historical risk factors, two items relating to patient activation, 13 items signifying core clinical signs, five items for change analysis and five items regarding the ongoing patient management plan.

RESULTS

Two hundred medical records from 151 patients with age-related macular degeneration were analysed. There was a statistically significant improvement in the number of reports that explicitly specified the number of clinical structural risk factors (from 24 to 75%; Fisher's exact p < 0.001) and risk of progression to advanced disease (from 71 to 84%; p = 0.041); however, this documentation had no statistically significant effect on the report-recommended management plan and/or the final report-recommended review period.

CONCLUSION

Disease-specific, structured record keeping improves the outgoing documentation of key clinical signs and is effective in prompting the transposition of these signs into a quantified risk progression score. It has limited value in improving management consistency among a group of highly trained eye care staff.

Review of referrals reveal the impact of referral content on the triage and management of ophthalmology wait lists

OBJECTIVES

Many chronic eye conditions are managed within public hospital ophthalmology clinics resulting in encumbered wait lists. Integrated care schemes can increase system capacity. In order to direct implementation of a public hospital-based integrated eye care model, this study aims to evaluate the quality of referrals for new patients through information content, assess triage decisions of newly referred patients and evaluate the consistency of referral content for new patients referred multiple times.

DESIGN

A retrospective and prospective review of all referral forms for new patients referred to a public hospital ophthalmology clinic between January 2016 and September 2017, and September 2017 and August 2018, respectively.

SETTING

A referral-only public hospital ophthalmology clinic in metropolitan Sydney, Australia.

PARTICIPANTS

418 new patients on existing non-urgent wait lists waiting to be allocated an initial appointment, and 528 patients who were newly referred.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the information content of referrals for new patients. The secondary outcomes were triage outcomes for new incoming referrals, and the number of new patients with multiple referrals.

RESULTS

Of the wait-listed referrals, 0.2% were complete in referral content compared with 9.8% of new incoming referrals (p<0.001). Of new incoming referrals, 56.7% were triaged to a non-urgent clinic. Multiple referrals were received for 49 patients, with no change in the amount of referral content.

CONCLUSIONS

Most referrals were incomplete in content, leading to triage based on limited clinical information. Some new patients were referred multiple times with their second referral containing a similar amount of content as their first. Lengthy wait lists could be prevented by improving administrative processes and communication between the referral centre and referrers. The future implementation of an integrated eye care model at the study setting could sustainably cut wait lists for patients with chronic eye conditions.

Dietary Intakes, Scores and Serum Lutein and Zeaxanthin Levels in Selected Adult Australian Population

Objectives

Age-related macular degeneration (AMD) is one of the leading causes of blindness in Australia and globally. Many studies have reported dietary and non-dietary risk associated factors to AMD, but few studies have focused on the dietary intakes and relative bioavailability of serum lutein (L) and zeaxanthin (Z). This study aimed to assess the dietary intakes, scores and serum L and Z levels in a selected Australian Adult population.

Methods

A cross-sectional study involving 33 healthy adults aged 19–29 and 30–52 years was carried out. Background demographic information on all participants was obtained using an online self-administered questionnaire while diet intakes were obtained using the USDA's 24 hours recall questionnaire, the Victorian Cancer Council

(Australia) food frequency questionnaire. Serum L and Z levels were determined using HPLC. Dietary intakes, scores against serum L, Z, and L + Z were established using descriptive statistics, Pearson's correlation, and multiple regression.

Results

Mean serum concentration of L + Z were higher in older vs younger adults (49.0 ± 10.0 μg/dL vs 43.0 ± 14.0 μg/dL) whereas dietary intakes were lower (15.7 μg/100 g vs 18.7 μg/100 g). Percentage (%) dietary scores were slightly higher among the older age group (43.0% vs 41.3%). Among women vs men, women had higher scores, dietary intakes of L + Z (19.3 μg/100 g vs 15.0 μg/100 g) and % dietary scores (43.9% vs 40.1%). There was no observed gender difference in serum L + Z levels (46.0 ± 12.0 μg/dL). Serum L + Z levels correlated more with the ethnic group of African descent (P = 0.357, P &lt; 0.022) and duration of residency (&gt;10 years) (P = 0.348, P = 0.025). About 59% of participants had L/Z ratio of either 3 : 1 or 4 : 1. Multivariate regression identified percentage dietary scores, ethnicity, age as major predictors of serum L + Z concentrations (R2 = 0.837).

Conclusions

Established age-specific reference range for dietary intakes and serum L + Z levels is required to determine populations at risk of AMD. Women are making better food choices than men. This was apparent in dietary intakes, scores. Ethnicity and longer residency status in Australia correlated with serum L + Z concentrations.

Funding Sources

None.

Topical Review: Assessment of Binocular Sensory Processes in Low Vision

SIGNIFICANCE

This article summarizes the evidence for a higher prevalence of binocular vision dysfunctions in individuals with vision impairment. Assessment for and identification of binocular vision dysfunctions can detect individuals experiencing difficulties in activities including reading, object placement tasks, and mobility.Comprehensive vision assessment in low vision populations is necessary to identify the extent of remaining vision and to enable directed rehabilitation efforts. In patients with vision impairment, little attention is typically paid to assessments of binocular vision, including ocular vergence, stereopsis, and binocular summation characteristics. In addition, binocular measurements of threshold automated visual fields are not routinely performed in clinical practice, leading to an incomplete understanding of individuals' binocular visual field and may affect rehabilitation outcomes.First, this review summarizes the prevalence of dysfunctions in ocular vergence, stereopsis, and binocular summation characteristics across a variety of ocular pathologies causing vision impairment. Second, this review examines the links between clinical measurements of binocular visual functions and outcome measures including quality of life and performance in functional tasks. There is an increased prevalence of dysfunctions in ocular alignment, stereopsis, and binocular summation across low vision cohorts compared with those with normal vision. The identification of binocular vision dysfunctions during routine low vision assessments is especially important in patients experiencing difficulties in activities of daily living, including but not limited to reading, object placement tasks, and mobility. However, further research is required to determine whether addressing the identified deficits in binocular vision in low vision rehabilitative efforts directly impacts patient outcomes.

Dietary Lutein, Zeaxanthin and Omega-3- Essential Fatty Acid Intake and Risk of Age-Related Macular Degeneration in a Selected Australian Population

Objectives

The aim of this study was to assess the dietary intakes of lutein, zeaxanthin (L + Z) and omega-3-essential fatty acid(EFA) among a selected population of Australian based adults and to examine the effect of specified risk factors for age-related macular degeneration(AMD) on those levels.

Methods

A cross-sectional study involving 70 adults aged 19–52 years was carried out. Demographic data were obtained using an online self-administered questionnaire while dietary intakes were estimated using USDA's 24 hours recall questionnaire, the Victorian Cancer Council(Australia) food frequency questionnaire and anthropometric characteristics were obtained using a body composition analyzer. Dietary intakes of lutein, zeaxanthin, omega-3-EFA and anthropometric indices against the risk of AMD were established using descriptive statistics and Spearman correlation.

Results

The mean age of the population was 29.9 ± 8.1years with 51% men and 49% women. Women had a higher intake of L + Z (1908.6 μg/day versus 1032.8 μg/day) and alpha-linolenic acid(ALA) compared to men(1.7 ± 1.1 g/day versus 1.6 ± 1.2 g/day). Men consumed more omega-3-EFA than women (433 ± 397.1 mg/day versus 365 ± 210.7 mg/day). L + Z levels were higher among people of Middle Eastern and South Asian origin (&gt;4000 μg/day) in the 19–25years age group. People of Middle Eastern, South East Asian and South Asian had the highest intake of omega-3-EFA(&gt;500 mg/day) at ages 19–25, 26–32 and 34–52years respectively. Women aged 34–52years with a family history of AMD had higher levels of L + Z(&gt;2500 μg/day) while women aged 26–32years with a family history of AMD had higher levels of ALA(&gt;3 g/day). Ethnicity and L + Z were correlated (P = −0.456, P &lt; 0.02). Higher levels of intake of L + Z (&gt;4000 μg/day) were seen in participants aged 34–52years with a 5–10years residence in Australia. Participants who had less than 5–10years of residency had higher levels of omega-3-EFA(&gt;500 mg/day) for ages 26–32years while those aged 34–52years who had less than 5years of residency had higher ALA(&gt;4 g/day).

Conclusions

Intake levels for L + Z vary significantly among participants. Culturally specific dietary habits could feasibly influence the levels of intake of L + Z. Intake levels of omega-3-EFA were met. This study provides detailed intake levels of L + Z and omega-3-EFA for the ‘at-risk’ AMD group.

Funding Sources

No funding source.

Evaluation of a hospital-based integrated model of eye care for diabetic retinopathy assessment: a multimethod study

OBJECTIVES

Diabetic eye disease is a leading cause of blindness but can be mitigated by regular eye assessment. A framework of issues, developed from the literature of barriers to eye assessment, was used to structure an examination of perceptions of a new model of care for diabetic retinopathy from the perspective of staff using the model, and health professionals referring patients to the new service.

DESIGN

Multimethod: interviews and focus groups, and a separate survey.

SETTING

A new clinic based on an integrated model of care was established at a hospital in outer metropolitan Sydney, Australia in 2017. Funded jointly by Centre for Eye Health (CFEH) and the hospital, the clinic was equipped and staffed by optometrists who work alongside the ophthalmologists in the existing hospital eye clinic.

PARTICIPANTS

Five (of seven) hospital staff working in the clinic (ophthalmologists and administrative officers) or referring to it from other departments (endocrinologists); nine optometrists from CFEH who developed or worked in the clinic; 10 community-based optometrists as potential referrers.

RESULTS

The new clinic was considered to have addressed known barriers to eye assessment, including access, assistance for patients unable/unwilling to organise eye checks and efficient management of human resources. The clinic optimised known drivers of this model of care: providing clear scope of practice and protocols for shared care between optometrists and ophthalmologists, good communication between referrers and eye professionals and a collegial approach promoting interprofessional trust. Remaining areas of concern were few referrals from general practitioners, fewer referrals from hospital endocrinologists than expected and issues with stretched administrative capacity. There were also perceived mismatches between the priorities of hospital management and aims of the clinic.

CONCLUSIONS

The new model was considered to have addressed many of the barriers to assessment. While there remain issues with the model, there were also unexpected benefits.

Posterior segment conditions associated with myopia and high myopia

Myopia, and especially high myopia, is associated with a number of posterior segment changes that are considered to be mostly a consequence of the increased axial elongation. This can result in mechanical strain, attendant vascular changes, stretching and thinning of tissues, and atrophy/deformation of tissues in later or more advanced stages. Such myopia-related changes are observed as changes and/or abnormalities in the vitreous, choroid, retina and peripheral retina, sclera and/or optic disc. Although many of these changes are benign, at times they may be associated with significant vision impairment that either requires active intervention or may suggest future progression of the disease. This review systematically addresses the posterior segment conditions seen in myopic eyes, describes the features associated with the condition and details management pathways.

Bayesian rank-based hypothesis testing for the rank sum test, the signed rank test, and Spearman's ρ

Bayesian inference for rank-order problems is frustrated by the absence of an explicit likelihood function. This hurdle can be overcome by assuming a latent normal representation that is consistent with the ordinal information in the data: the observed ranks are conceptualized as an impoverished reflection of an underlying continuous scale, and inference concerns the parameters that govern the latent representation. We apply this generic data-augmentation method to obtain Bayes factors for three popular rank-based tests: the rank sum test, the signed rank test, and Spearman's ρs.

Interocular asymmetry of the superonasal retinal nerve fibre layer thickness and blood vessel diameter in healthy subjects

Background

Optical coherence tomography is commonly used to measure the retinal nerve fibre layer thickness in both normal and diseased eyes; however, variation among normal eyes is common and may limit the usefulness of the results. The aim of this study was to explore the interocular asymmetries in retinal nerve fibre layer thickness in a group of normal eyes and to investigate the influence of blood vessel diameter on local retinal nerve fibre layer thickness.

Methods

In this prospective study, retinal nerve fibre layer thickness and blood vessel diameter across 100 healthy participants were measured using two optical coherence tomography instruments. Individuals were categorised into two groups based on the presence or absence of interocular retinal nerve fibre layer thickness asymmetry beyond the 75^th percentile of all participants.

Results

The superonasal sectoral retinal nerve fibre layer thickness was significantly greater in the left eye compared to the right, across all three sectors. Mean blood vessel diameter showed a corresponding difference in thickness at one of the superonasal sectors. Linear regression showed a positive and moderate correlation between blood vessel diameter and focal retinal nerve fibre layer thickness. This trend persisted across both arteries and veins, but veins showed larger variability between left and right eye in participants with marked superonasal retinal nerve fibre layer asymmetry.

Conclusion

Retinal nerve fibre layer thickness and blood vessel diameter vary significantly between eyes even in healthy individuals. These asymmetries in a normal population should be taken into consideration when interpreting the retinal nerve fibre layer thickness measurements from optical coherence tomography to assist in distinguishing normal variations from disease.

Impact of referral refinement on management of glaucoma suspects in Australia

BACKGROUND

In ageing populations, the prevalence of chronic diseases such as glaucoma is projected to increase, placing additional demands on limited health-care resources. In the UK, the demand for secondary care in hospital eye clinics was inflated by high rates of false positive glaucoma referrals. Collaborative care models incorporating referral refinement, whereby glaucoma suspect referrals are triaged by suitably trained optometrists through further testing, can potentially reduce false positive referrals. This study examined the impact of a referral refinement model on the accuracy of glaucoma referrals in Australia.

METHODS

Optometrist-initiated glaucoma suspect referrals to the Glaucoma Management Clinic (Sydney, Australia) were prospectively recruited. Glaucoma suspect referrals arising from two pathways were eligible for inclusion, either directly from a community optometrist (standard care) or following comprehensive assessment at the Centre for Eye Health (referral refinement). Main outcome measures were the positive predictive value and false positive rate of referrals. The impact of referral letter content on management outcomes was also investigated.

RESULTS

Of 464 referrals received between March 2015 and June 2018, 252 were for treatment of naïve glaucoma suspects and eligible for inclusion. Following ophthalmological assessment, 45.6 per cent (n = 115/252) were prescribed treatment for open angle glaucoma or ocular hypertension. Positive predictive value of community optometry referrals was 33.8 per cent (n = 25/74) and 50.6 per cent (n = 90/178) following referral refinement. The first visit discharge (false positive) rate was 26 per cent (n = 19/74) for community referrals compared to four per cent (n = 8/178) with referral refinement. Positive predictive value increased with the number of abnormal clinical examination findings associated with referral (χ² test, p < 0.0001). The number of abnormal findings reported in referrals was significantly higher with referral refinement compared to without (n = 1.9 versus 1.5, t-test, p < 0.0001).

CONCLUSION

Referral refinement can improve the diagnostic accuracy of optometry-initiated referrals for glaucoma suspects in Australia, thereby decreasing unnecessary referrals to hospital and other secondary clinics.

Multimodal imaging characteristics of congenital grouped hyper- and hypo-pigmented fundus lesions

BACKGROUND

The imaging characteristics of congenital grouped pigmentation of the retinal pigment epithelium (CGP-RPE) and its non-pigmented variant - grouped congenital albinotic retinal pigment epithelial spots (GCARPES) are poorly defined in the literature. Our case series reports their multimodal imaging characteristics across a spectrum of presentations.

METHODS

A retrospective review of patient records was conducted on patients seen at the Centre for Eye Health between January and December 2016. The multimodal imaging findings across four cases is described using optical coherence tomography (OCT), infrared imaging, ultra-widefield imaging, fundus photography and fundus autofluorescence (FAF).

RESULTS

Case 1 is a 55-year-old female with a bilateral presentation of CGP-RPE showing typical features. Case 2 is a 28-year-old male with a classical presentation of GCARPES in the left eye. Case 3 is a 33-year-old female with unilateral CGP-RPE and an atypical solitary congenital hypertrophy of the retinal pigment epithelium (CHRPE) in the same eye. Case 4 is a unilateral presentation in an 11-year-old female with unusual characteristics. Ocular imaging characteristics of CGP-RPE lesions varied between patients: OCT showed visible RPE changes in cases 3 and 4 but not case 1. The pattern of FAF and infrared imaging also varied with most lesions displaying a pattern of hypo-autofluorescence, but some central lesions in case 3 exhibited hyper-autofluorescence. All lesions were visible with fundus photography.

CONCLUSION

FAF can be helpful in alerting clinicians to the presence of lesions that may be difficult to visualise funduscopically and OCT can be helpful in differentiating between CGP-RPE and its variants from more sinister ocular conditions. All in all, these findings highlight the variable manifestation of CGP-RPE and its variants on multimodal imaging; the diagnosis of CGP-RPE and its variants should remain based on its characteristic funduscopic appearance.

Optometry Australia's chairside reference for the diagnosis and management of age-related macular degeneration

Age-related macular degeneration (AMD) is the leading cause of irreversible vision loss in people over the age of 50 years in Australia. Optometry Australia has developed this AMD chairside reference in consultation with a member-based working group comprised of experienced practitioners. It provides an evidence-based approach to current best practice in the diagnosis and management of AMD. Optometrists should be competent in assessing patients with or at risk of developing AMD, so that they are able to provide evidence-based management including appropriate communication, diagnosis and referral when indicated. This AMD chairside reference covers risk factors for the development of AMD or progression to late-stage AMD; the current clinical classification of AMD; common signs and symptoms; optometric assessment including ocular imaging and biomarkers; differential diagnoses; and management of early, intermediate and late AMD. Optometry Australia's chairside reference is intended as a general guide for optometrists, and is not a formal management protocol.

Peripheral retinal findings in populations with macular disease are similar to healthy eyes

PURPOSE

Recent evidence suggests several macular diseases are associated with peripheral retinal changes. This study investigated the number, type and management consequences of peripheral retinal findings detected in patients attending a referral only, eye-care clinic, the Centre for Eye Health(CFEH) with macular disease.

METHODS

Records of 537 patients attending CFEH for a macular assessment were included in the study. Subjects were classified as having age-related macular degeneration (AMD), epiretinal membrane (ERM), central serous chorioretinopathy (CSCR), inherited macular dystrophy or no macular disease. Data extracted included reason for referral, macular findings, peripheral findings (based on examination by ultra-widefield scanning laser ophthalmoscopy), diagnosis and management.

RESULTS

After age-matching, the number of peripheral findings in subjects with AMD, ERM or CSCR was not significant different to normal subjects. The most common finding for all cohorts were non-specific, degenerative changes such as drusen or pigmentation (61-72%) except inherited macular dystrophy subjects who had mostly vascular findings (30%; p < 0.05). Subjects with AMD and ERM with peripheral findings were significantly more likely to be reviewed or referred to an ophthalmologist than discharged back to their community eye care provider compared to subjects without findings. However only 8% of subjects had altered management based specifically on peripheral findings suggesting the macular findings in most subjects dictated their management. For those with a change, it was significant (upgrade to referral to an ophthalmologist). Peripheral findings also flagged 5% of subjects with vascular findings for referral to their general practitioner (GP).

CONCLUSIONS

Overall, the percentage and distribution of peripheral retinal findings in some macular diseases was similar to normal subjects. However, subjects with peripheral findings appeared to have significant differences in management. Considering some common findings, such as peripheral drusen may be relevant to AMD pathogenesis and therefore affect management of this disease, assessment of the peripheral retina should not be overlooked when the clinical focus is on the posterior pole.

Multispectral Pattern Recognition Reveals a Diversity of Clinical Signs in Intermediate Age-Related Macular Degeneration

Purpose

To develop a proof-of-concept, computational method for the quantification and classification of fundus images in intermediate age-related macular degeneration (AMD).

Methods

Multispectral, unsupervised pattern recognition was applied to 184 fundus images from 10 normal and 36 intermediate AMD eyes. The imaging results of preprocessed, grayscale images from three modalities (infrared, green, and fundus autofluorescence scanning laser ophthalmoscopy) were automatically classified into various clusters sharing a common spectral signature, using a k-means clustering algorithm. Class separability was calculated by using transformed divergence (DT). The classification results for large drusen, pigmentary abnormalities, and areas unaffected by AMD were compared against three expert observers for concordance, and to calculate sensitivity and specificity.

Results

Multispectral, unsupervised pattern recognition successfully identified a finite number of AMD-specific, statistically separable signatures in eyes with intermediate AMD. By using a correct classification criterion of >83% for identical clusters and a total of 1693 expert annotations, the sensitivity and specificity of multispectral pattern recognition for the detection of AMD lesions was 74% and 98%, respectively. Large drusen and pigmentary abnormalities were correctly classified in 75% and 68% of instances, respectively.

Conclusions

We describe herein a novel approach for the classification of multispectral images in intermediate AMD. Automated classification of intermediate AMD, using multispectral pattern recognition, has moderate sensitivity and high specificity, when compared against clinical experts. The methods described may have a future role in AMD screening or monitoring.

An evidence-based approach to the routine use of optical coherence tomography

Optical coherence tomography is an imaging technology that has revolutionised the detection, assessment and management of ocular disease. It is now a mainstream technology in clinical practice and is performed by non-specialised personnel in some settings. This article provides a clinical perspective on the implications of that movement and describes best practice using multimodal imaging and an evidence-based approach. Practical, illustrative guides on the interpretation of optical coherence tomography are provided for three major diseases of the ocular fundus, in which optical coherence tomography is often crucial to management: age-related macular degeneration, diabetic retinopathy and glaucoma. Topics discussed include: cross-sectional and longitudinal signs in ocular disease, so-called 'red-green' disease whereby clinicians rely on machine/statistical comparisons for diagnosis in managing treatment-naïve patients, and the utility of optical coherence tomography angiography and machine learning.

Finding Adequate Information: A Major Challenge for Policy-Makers in the Field of Cancer

Background and context: A global cancer epidemic is developing (GLOBOCAN 2012). In the case of low- and-middle-income countries, difficulties are cumulative: inadequate health systems, lack of training for professionals. Drastic decisions have to be taken in a very complex field. Good decision needs good information. What about information dedicated to policy-makers: to decide a question, they need specific information, marked by these features: synthetic, clear, scientifically validated. Actually, this is not easy to find. Moreover policy-makers can't really benefit from: 1. Information for health professionals which is complex and overabundant (the request “cancer” on PubMed “out” nearly 1.5 millions references). 2. Documents or testimonials for patients. Written by scientific societies or patients' associations, they mostly focus on 2 topics “understand your disease” and “how to cope with”. 3. Information from the Web, not always reliable in terms of quality. Strategy/Tactics: While policy advisors and international organizations provide appropriate studies and reports, mostly focused on “what should be done”, we believe that knowledge of basic cancer data are necessary to understand the proposals. We talk about issues like “what is cancer”, “what exactly cover radiotherapy, oncological surgery…”. Regarding French speaking Africa, Alliance Ligues Africaines and Méditérranéennes (ALIAM) and The French League have produced targeted information for decision-makers. The document was presented in Brazzaville in June 2017. Access to this book is free: www.livre-cancer.aliam.org . The editorial method was discussed and we made the choice to write short sheets, to quickly understand the useful definitions and problems. Rather than comprehensiveness, a pedagogical will and a desire for clarity guided the writing. Diagrams and photos had to be abundant to facilitate understanding. Moreover, this format allows a permanent update of the subjects and the introduction of new topics as needed. What was learned: On the basis of this experience, ALIAM and the league are convinced that a pedagogic document with an international vocation would be useful for all policy makers. Proposal for action: UICC would be the perfect organizer of a working group to produce such a document. The goal would be to develop a consensus text which resume essential data on all common themes of cancer. About 25 themes could be identified, e.g., definition and mechanisms of development of cancers, risk factors, screening and early diagnosis, anatomic pathology and telepathology, molecular biology, imaging and interventional radiology, surgery, radiotherapy, chemotherapy and innovative therapies, palliative care etc. Moreover, focus on specific location of cancer (breast, cervix, lung…) and pediatric cancers should be developed. Then, it would be easier for any world regions to supplement this validated information with additional specific data describing the local situation. Hierarchizing action priorities would be facilitated.

The advantages of intermediate-tier, inter-optometric referral of low risk pigmented lesions

Purpose

Pigmented ocular lesions are commonly encountered by eye‐care professionals, and range from benign to sight or life‐threatening. After identifying a lesion, the primary care professional must establish the likely diagnosis and decide either to reassure, to monitor or to refer. The increasing use of ocular imaging technologies has contributed to an increase in the detection rate of pigmented lesions and a higher number of referrals, which may challenge existing pathways of health‐care delivery. Specialist services may be over‐burdened by referring all patients with pigmented lesions for an opinion, while inter‐optometric referrals are underutilised. The aim of this study was to describe the referral patterns of pigmented lesions to an optometry led intermediate‐tier collaborative care clinic.

Methods

We performed a retrospective review of patient records using the list of patients examined at Centre for Eye Health (CFEH) for an initial or follow up pigmented lesion assessment between the 1/7/2013 and the 30/6/2016. Analysis was performed on: patient demographic characteristics, the referrer's tentative diagnosis, CFEH diagnosis and recommended management plan.

Results

Across 182 patient records, the primary lesion prompting referral was usually located in the posterior segment: choroidal naevus (105/182, 58%), congenital hypertrophy of the retinal pigment epithelium (CHRPE; 11/182, 6%), chorioretinal scarring (10/182, 5%) or not specified (52/182, 29%). Referrals described a specific request for ocular imaging in 25 instances (14%). The number of cases with a non‐specific diagnosis was reduced after intermediate‐tier care assessment (from 29% to 10%), while the number of diagnoses with less common conditions rose (from 2% to 21%). There was a 2% false positive referral rate to intermediate‐tier care and a first visit discharge rate of 35%. A minority required on‐referral to an ophthalmologist (22/182, 12%), either for unrelated incidental ocular findings, or suspicious choroidal naevi. Conditions most amenable to optometric follow up included: 1) chorioretinal scarring, 2) choroidal naevus, and 3) CHRPE.

Conclusions

Intermediate‐tier optometric eye‐care in pigmented lesions (following opportunistic primary care screening) has the potential to reduce the number of cases with non‐specific diagnoses and to increase those with less common diagnoses. The majority of cases seen under this intermediate‐tier model required only ongoing optometric surveillance.

Developing prognostic biomarkers in intermediate age-related macular degeneration: their clinical use in predicting progression

Age-related macular degeneration is a common, complex and blinding eye disease. When early and intermediate levels of severity are detected in one or both eyes, there is a wide-ranging 0.4 to 53 per cent risk of progression to advanced disease in five years. In order to maximise visual outcomes for their patients, practising eye-care professionals must be able to stratify patients according to their risk of progression, intervene (for example by recommending smoking cessation or nutritional supplements and Amsler grid self-monitoring in intermediate disease) and monitor accordingly. With the aid of ocular imaging, a range of under-recognised yet meaningful risk factors have been identified. The purpose of this review is to assist the eye-care practitioner in stratifying the risk of progression in intermediate age-related macular degeneration using the range of established and emerging precursory signs that herald loss of vision.

Advanced imaging for the diagnosis of age-related macular degeneration: a case vignettes study

Background

The aim of this study is to evaluate the diagnosis, staging, imaging and management preferences, and the effect of advanced imaging among practising optometrists in age‐related macular degeneration (AMD).

Methods

Up to 20 case vignettes (computer‐based case simulations) were completed online in a computer laboratory in random order by 81 practising optometrists of Australia. Each case presented findings from a randomly selected patient seen previously at the Centre for Eye Health for a macular assessment in the following order: case history, preliminary tests and colour fundus photography. Participants were prompted to provide their diagnosis, management and imaging preference. One additional imaging result (either modified fundus photographs and infrared images, fundus autofluorescence, or optical coherence tomography [OCT]) was then provided and the questions repeated. Finally, all imaging results were provided and the questions repeated a third time.

Results

A total of 1,436 responses were analysed. The presence of macular pathology in AMD was accurately detected in 94 per cent of instances. The overall diagnostic accuracy of AMD was 61 per cent using colour fundus photography. This improved by one per cent using one additional imaging modality and a further four per cent using all imaging. Across all responses, a greater improvement in the diagnostic accuracy of AMD occurred following the presentation of OCT findings (versus other modalities). OCT was the most preferred imaging modality for AMD, while multimodal imaging was of greatest benefit in cases more often misdiagnosed using colour fundus photography alone. Overall, the cohort also displayed a tendency to underestimate disease severity.

Conclusion

Despite reports that imaging technologies improve the stratification of AMD, our findings suggest that this effect may be small when applied among practising optometrists without additional or specific training.

Collaborative care of non-urgent macular disease: a study of inter-optometric referrals

Purpose

Diseases involving the macula and posterior pole are leading causes of visual impairment and blindness worldwide and may require prompt ophthalmological care. However, access to eye‐care and timely patient management may be limited due to inefficient and inappropriate referrals between primary eye‐care providers and ophthalmology. Optometrists with a special interest in macular disease may be useful as a community aid to better stratify and recommend best‐practice management plans for suitable patients. This study assesses such a notion by appraising the optometric referral patterns of patients with suspected macular disease to an intermediate‐tier optometric imaging clinic.

Methods

We performed a retrospective review of patient records and referrals using patients examined at Centre for Eye Health (CFEH) for an initial or follow up macular assessment between the 1/7/2013 and 30/6/2014 (n = 291). The following data were analysed: patient demographic characteristics, primary reason for referral, diagnosed/suspected condition, CFEH diagnosis and recommended management plan.

Results

The number of referrals stipulating a diagnosis, confirmed after evaluation at CFEH was 121 of 291 (42%). After evaluation at CFEH, the number of cases without a specific diagnosis was approximately halved (reduced from 47% to 23%), while the number of cases with no apparent defect or normal aging changes rose from 1% to 15%. Overall diagnostic congruency for specified macular conditions was high (58–94%); cases were seldom (30/291, 10%) found to have a completely different macular condition. 244 of 291 (84%) patients seen at CFEH were recommended ongoing optometric care: either with the referring optometrist or through recall to CFEH. Referral to an ophthalmologist was recommended in 47 instances (16%).

Conclusions

More widespread adoption of intermediate‐tier optometric eye‐care referral pathways in macular disease (following opportunistic primary care screening) has the potential to reduce the number of cases with non‐specific diagnoses and to increase those with a diagnosis of normal aging changes or no apparent disease. The majority of cases seen under this intermediate‐tier model required ongoing optometric care only and did not require face‐to‐face consultation with an ophthalmologist.

Infrared reflectance imaging in age-related macular degeneration

PURPOSE

The purpose of this article is to describe the appearance of age-related macular degeneration (AMD) phenotypes using infrared (IR) reflectance imaging. IR reflectance imaging of the retina has the potential to highlight specific sub-retinal features and pathology. However, its role in macular disease, specifically AMD, is often underestimated and requires clarification.

RECENT FINDINGS

Recent advances in clinical methods, imaging and scientific knowledge may be integrated to improve the accuracy of disease stratification in AMD. In particular, IR imaging holds an underutilised sensitivity to detect reticular pseudodrusen, which have been repeatedly described as a high-risk sign for late AMD.

SUMMARY

This article provides clinically relevant descriptions of AMD phenotypes using IR reflectance imaging. The findings are integrated with images from cases seen at the Centre for Eye Health. As primary eye-care providers assume a critical role in the detection, diagnosis and management of AMD, we also provide a chair-side reference to assist clinicians in interpreting IR images in AMD.

Self-reported optometric practise patterns in age-related macular degeneration

BACKGROUND

The use of advanced imaging in clinical practice is emerging and the use of this technology by optometrists in assessing patients with age-related macular degeneration is of interest. Therefore, this study explored contemporary, self-reported patterns of practice regarding age-related macular degeneration diagnosis and management using a cross-sectional survey of optometrists in Australia and New Zealand.

METHODS

Practising optometrists were surveyed on four key areas, namely, demographics, clinical skills and experience, assessment and management of age-related macular degeneration. Questions pertaining to self-rated competency, knowledge and attitudes used a five-point Likert scale.

RESULTS

Completed responses were received from 127 and 87 practising optometrists in Australia and New Zealand, respectively. Advanced imaging showed greater variation in service delivery than traditional techniques (such as slitlamp funduscopy) and trended toward optical coherence tomography, which was routinely performed in age-related macular degeneration by 49 per cent of respondents. Optical coherence tomography was also associated with higher self-rated competency, knowledge and perceived relevance to practice than other modalities. Most respondents (93 per cent) indicated that they regularly applied patient symptoms, case history, visual function results and signs from traditional testing, when queried about their management of patients with age-related macular degeneration. Over half (63 per cent) also considered advanced imaging, while 31 per cent additionally considered all of these as well as the disease stage and clinical guidelines. Contrary to the evidence base, 68 and 34 per cent rated nutritional supplements as highly relevant or relevant in early age-related macular degeneration and normal aging changes, respectively.

CONCLUSIONS

These results highlight the emergence of multimodal and advanced imaging (especially optical coherence tomography) in the assessment of age-related macular degeneration by optometrists. Clinically significant variations in self-rated test competency and the understanding regarding nutritional supplements for different stages of age-related macular degeneration suggest that further work to up-skill optometrists may be required.

Abstract P2-05-06: Analytical and clinical validation of a fully automated tissue-based quantitative assay (MetaSite Breast™) to detect the likelihood of distant metastasis in hormone receptor (HR)-positive, HER2-negative early stage breast cancer (ESBC)

Background: MetaSite Breast™ is a validated assay to predict risk of distant breast cancer metastasis in patients with HR+/HER2- ESBC. The assay measures the number of MetaSites defined as tumor microanatomic structures composed of MENA protein expressing tumor cells in contact with CD31+ endothelial cells and CD68+ macrophages. Previous studies have demonstrated that an increased number of these microanatomic structures is associated with distant metastasis (DM) in HR+/HER2- ESBC independent of clinicopathologic features. Analytical validation of MetaSite Breast™ demonstrated precision of 97-99% (repeat image analysis of the same slide) and performance of 91-96% (staining and image analysis of serial tumor sections). We sought to further understand the importance of the MetaSite in predicting distant breast cancer metastasis utilizing a fully automated prognostic assay in an independent large patient cohort.

Methods: We conducted a nested case-control study within a cohort of 3,760 patients diagnosed between 1980 and 2000 with invasive breast cancer from the Kaiser Permanente Northwest health care system. Cases (n=259) were women who developed a subsequent distant metastasis; controls, selected using incidence density sampling, were matched closely to cases (1:1) on age at and calendar year of primary diagnosis. Of the 481 patient tumor samples evaluated in this study, 57% were HR+/HER2-, 19% were triple negative (TN), and 15% were HER2+ disease. Multivariate models were adjusted for clinical factors including: lymph node status, tumor size, tumor grade, and HRT; as well as matching variables: age and year of diagnosis. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression.

Results: In the HR+/HER2- group, MetaSite Score (MS) ranged from 0-357 and the mean was 44.6. MS was a significant predictor of DM (P=0.039) in patients with HR+/HER2- disease. Cut-points based on tertiles of MS in all 259 controls defined intermediate (13-41) and high (&gt;41) risk groups that were significantly associated with risk of DM versus the low risk group (OR=2.24; 95%CI=1.23-4.13, P=0.009) and (OR=2.94; 95%CI=1.62-5.41, P=0.0005), respectively. Univariate estimates of absolute risk of DM with cutoffs based on 90% sensitivity and specificity were 9.4% for the low risk group (MS&lt;7), 14.1% for the intermediate (MS=7-91), and 23.4% for the high (MS&gt;91). When adjusted for clinical factors, estimates of absolute risk of DM were 6.6%, 14.1%, and 33.0% for the low, intermediate, and high risk groups, respectively. A binary cut-point for the high risk group was determined (MS&gt;14) and was significant with a 2-fold higher risk of DM versus the low risk group and adjusted for clinical covariates (P=0.036). MS was not positively associated with DM in TN or HER2+ disease.

Conclusions: MetaSite Breast™ significantly predicted the risk of distant breast cancer metastasis in ESBC patients with HR+/HER2-disease, independent of classical clinicopathologic features.

Citation Format: Donovan MJ, Jones JG, Entenberg DR, Condeelis JS, D'alfonso TM, Gustavson M, Molinaro A, Oktay MH, Xue X, Sparano JA, Peterson MA, Podznyakova O, Rohan TE, Shuber AP, Gertler FB, Ly A, Divelbiss ME, Hamilton DA. Analytical and clinical validation of a fully automated tissue-based quantitative assay (MetaSite Breast™) to detect the likelihood of distant metastasis in hormone receptor (HR)-positive, HER2-negative early stage breast cancer (ESBC) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-05-06.

Abstract P2-05-08: Impact of treatment history on prognostic ability of breast cancer index (BCI): Subset analysis from a validation study of patients with hormone receptor-positive (HR+) breast cancer with 1-3 positive nodes

Background: A new BCI model integrating tumor size and grade (BCIN+) was specifically developed and validated for prediction of risk of overall (0-15y) and late (5-15y) distant recurrence (DR) in HR+ women with 1-3 positive nodes (N1). The objective of this study was to evaluate the impact of treatment history on the prognostic performance of BCIN+ in a large clinical validation cohort of pre- and post-menopausal HR+, N1 patients.

Methods: The validation cohort was comprised of 402 HR+, N1 patients diagnosed at Massachusetts General Hospital between 1993-2007 with at least 5y of follow-up. BCIN+ risk scores were determined and patients stratified into low or high risk categories using a pre-specified cut-point blinded to clinical outcome. Kaplan-Meier estimates of overall (0-15y) and late (5-15y) DR were estimated and the difference was evaluated by log-rank test. Treatment-specific subsets were analyzed based on adjuvant endocrine (tamoxifen [TAM] only vs any history of aromatase inhibitors [AI]), and adjuvant chemotherapy treatment history.

Results: Mean age of patients was 53y. 99% were ER+, 91% PR+, and 13% HER2+. The majority of tumors were T1 (62%) or T2 (35%). Adjuvant endocrine treatment included TAM only for 191 (48%) patients and either AI only or a sequence of TAM and an AI in 211 (52%) patients. Most patients received chemotherapy (n=324; 81%). BCIN+ classified 20% and 80% as low and high risk, respectively.

In patients treated with TAM only, BCIN+ low and high risk had significantly different 15y rates of DR (95% CI) of 4.0% (0.0-11.4%) vs 41.7% (33.0-49.3%), respectively (p=0.0005). For patients disease-free at year 5, rates of late DR (5-15y) were 4.0% (0.0-11.5%) vs 20.0% (11.4-27.8%), respectively (p=0.04). In patients treated with an AI, BCIN+ low and high risk had significantly different 15y rates of DR of 0% (0.0-0.0%) vs 15.0% (8.1-21.5%), respectively (p=0.006). For patients disease-free at year 5, rates of late DR were 0.0% (0.0-0.0%) vs 12.2% (5.6-18.3%), respectively (p=0.02). There was no statistically significant difference in the prognostic performance of BCIN+ between patients treated with TAM only versus those with treatment including any history of AI (interaction p=0.99).

In the subset of patients treated with chemotherapy, BCIN+ classified 19% and 81% of patients as low and high risk with significantly different 15y rates of DR of 1.7% (0.0-4.9%) vs 30.9% (24.4-36.8%), respectively (p&lt;0.0001). For patients disease-free at year 5, rates of late DR were 1.7% (0.0-4.9%) and 16.3% (10.2-21.9%), respectively (p=0.006).

Conclusions: In this subset analysis from a validation study of N1 patients, BCIN+ identified a significant proportion with a significantly low risk of late DR. This study confirms the ability of BCIN+ to identify a subset of patients with significantly low risk of recurrence across adjuvant endocrine and chemotherapy treatment backgrounds. BCIN+ may provide additional prognostic information to facilitate selection of N+ patients for extended endocrine treatment, wherein patients identified as BCIN+ low may be considered adequately treated with adjuvant therapy alone.

Citation Format: Zhang Y, Jerevall P-L, Schroeder BE, Ly A, Nolan H, Schnabel CA, Sgroi DC. Impact of treatment history on prognostic ability of breast cancer index (BCI): Subset analysis from a validation study of patients with hormone receptor-positive (HR+) breast cancer with 1-3 positive nodes [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-05-08.