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Künzel SH, Broadbent E, Möller PT, Lindner M, Goerdt L, Czauderna J, Schmitz-Valckenberg S, Holz FG, Pfau M, Fleckenstein M. Association of lesion location and functional parameters on vision-related quality of life in geographic atrophy secondary to AMD. Ophthalmol Retina 2024:S2468-6530(24)00057-5. [PMID: 38311207 DOI: 10.1016/j.oret.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 02/10/2024]
Abstract
OBJECTIVE The primary goal of this study was to determine how structural and functional parameters influence the vision-related quality of life (VRQoL) in patients suffering from geographic atrophy (GA) secondary to age-related macular degeneration. DESIGN This study was designed as a prospective, non-interventional, natural-history study (Directional Spread in Geographic-Atrophy study, NCT02051998). SUBJECTS The research involved 82 patients with bilateral GA. METHODS The study examined parameters including GA location as assessed by the Early Treatment Diabetic Retinopathy Study grid, best-corrected visual acuity (BCVA), low-luminance visual acuity (LLVA), reading acuity, and speed. These parameters were then correlated with VRQoL, which was gauged using the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ-25). The analysis method employed was the least absolute shrinkage and selection operator with linear mixed-effects models. MAIN OUTCOME MEASURES The central parameters measured in this study encompassed GA area, VRQoL scores associated with different GA subfields, and the significance of LLVA for foveal-sparing patients. RESULTS On average, patients showed a total GA area of 2.9 ± 1.2 mm2 in the better eye and 3.1 ± 1.3 mm2 in the worse eye. The most significant associations with VRQoL scores for distance and near activities were observed in the inner lower and inner left subfields of the better eye, respectively. For patients with foveal-sparing GA, the LLVA of the better eye stood out as the most influential variable across all VRQoL scales. CONCLUSIONS The study's findings point towards the pivotal role of GA location, especially the inner lower and inner left subfields of the better eye, in relation to VRQoL in GA patients. The LLVA's importance becomes even more pronounced for foveal-sparing patients. These observations highlight the need for healthcare professionals to better understand the association between lesion location and patient-reported outcomes. This is critical for informing treatment decisions and refining the planning of interventional trials.
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Affiliation(s)
| | - Eliza Broadbent
- Department of Ophthalmology & Visual Sciences, John A. Moran Eye Center, University of Utah, 65 North Mario Capecchi Drive, Salt Lake City, 84312, UT, United States
| | | | - Moritz Lindner
- Institute of Physiology and Pathophysiology, Department of Neurophysiology, Philipps University, Deutschhausstr. 1-2, Marburg 35037, Germany; Nuffield Laboratory of Ophthalmology, Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, South Parks Road, Oxford OX1 3QU, UK
| | - Lukas Goerdt
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | | | - Steffen Schmitz-Valckenberg
- Department of Ophthalmology, University of Bonn, Bonn, Germany; Department of Ophthalmology & Visual Sciences, John A. Moran Eye Center, University of Utah, 65 North Mario Capecchi Drive, Salt Lake City, 84312, UT, United States
| | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Maximilian Pfau
- Institute of Molecular and Clinical Ophthalmology Basel, Basel, Switzerland
| | - Monika Fleckenstein
- Department of Ophthalmology & Visual Sciences, John A. Moran Eye Center, University of Utah, 65 North Mario Capecchi Drive, Salt Lake City, 84312, UT, United States
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Künzel SH, Broadbent E, Möller PT, Lindner M, Goerdt L, Czauderna J, Schmitz-Valckenberg S, Holz FG, Pfau M, Fleckenstein M. Impact of lesion location and functional parameters on vision-related quality of life in geographic atrophy secondary to AMD. medRxiv 2023:2023.09.22.23295946. [PMID: 37790350 PMCID: PMC10543058 DOI: 10.1101/2023.09.22.23295946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Background/Aims The primary objective was to determine how structural and functional parameters influence the vision-related quality of life (VRQoL) in patients with geographic atrophy (GA) secondary to age-related macular degeneration (AMD). Methods This prospective, non-interventional, natural-history 'Directional Spread in Geographic-Atrophy' study was conducted at the University Eye Hospital in Bonn, enrolling 82 patients with bilateral GA. Parameters such as GA location (assessed by the Early Treatment Diabetic Retinopathy Study grid), best-corrected visual acuity (BCVA), low-luminance visual acuity (LLVA), reading acuity, and speed were examined. The association between these parameters and VRQoL, as gauged using the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ-25), was analyzed through least absolute shrinkage and selection operator with linear mixed-effects models. Results The average total GA area observed was 2.9 ± 1.2 mm2 (better eye) and 3.1 ± 1.3 mm2 (worse eye). The VRQoL scores for distance and near activities were most associated with the inner lower and inner left subfields of the better eye. For foveal-sparing patients, the LLVA of the better eye was the predominant determinate impacting all VRQoL scales. Conclusion GA location, specifically the inner lower and inner left subfields of the better eye, has a notable effect on VRQoL in GA patients. LLVA stands out as especially vital in foveal-sparing patients, underscoring the importance for clinicians to incorporate considerations of GA location and functional parameters into their risk-benefit assessments for emerging treatments.
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Affiliation(s)
| | - Eliza Broadbent
- Department of Ophthalmology & Visual Sciences, John A. Moran Eye Center, University of Utah, 65 North Mario Capecchi Drive, Salt Lake City, 84312, UT, United States
| | | | - Moritz Lindner
- Institute of Physiology and Pathophysiology, Department of Neurophysiology, Philipps University, Deutschhausstr. 1-2, Marburg 35037, Germany
- Nuffield Laboratory of Ophthalmology, Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, South Parks Road, Oxford OX1 3QU, UK
| | - Lukas Goerdt
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | | | - Steffen Schmitz-Valckenberg
- Department of Ophthalmology, University of Bonn, Bonn, Germany
- Department of Ophthalmology & Visual Sciences, John A. Moran Eye Center, University of Utah, 65 North Mario Capecchi Drive, Salt Lake City, 84312, UT, United States
| | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Maximilian Pfau
- Institute of Molecular and Clinical Ophthalmology Basel, Basel, Switzerland
| | - Monika Fleckenstein
- Department of Ophthalmology & Visual Sciences, John A. Moran Eye Center, University of Utah, 65 North Mario Capecchi Drive, Salt Lake City, 84312, UT, United States
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Dhooge PPA, Möller PT, Meland N, Stingl K, Boon CJF, Lotery AJ, Parodi MB, Herrmann P, Klein W, Fsadni MG, Wheeler-Schilling TH, Holz FG, Hoyng CB, Schmitz-Valckenberg S. Repeatability of Quantitative Autofluorescence Imaging in a Multicenter Study Involving Patients With Recessive Stargardt Disease 1. Transl Vis Sci Technol 2023; 12:1. [PMID: 36723966 PMCID: PMC9904328 DOI: 10.1167/tvst.12.2.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Purpose This study assesses the repeatability of quantitative autofluorescence (qAF) in a multicenter setting and evaluates qAF as the end point for clinical trials in recessive Stargardt disease 1 (STGD1). Methods A total of 102 patients with STGD1 underwent qAF imaging as part of the Stargardt Remofuscin Treatment Trial (STARTT; EudraCT No. 2018-001496-20). For 166 eyes, we obtained qAF imaging at 2 visits, with 2 recordings per visit. The qAF8 values were independently determined by the study site and a central reading center. Intra- and inter-visit reproducibility, as well as interobserver (study site versus reading center) reproducibility were obtained using intraclass correlation (ICC), one-sample t-test, and Bland-Altman coefficient of repeatability. Results The qAF repeatability was ± 26.1% for intra-visit, ± 40.5% for inter-visit, and ± 20.2% for the interobserver reproducibility measures. Intra-visit repeatability was good to excellent for all sites (ICC of 0.88-0.96). Variability between visits was higher with an overall ICC of 0.76 (0.69-0.81). We observed no significant difference in qAF values across sites between visits (7.06 ± 93.33, P = 0.238). Conclusions Real-life test-retest variability of qAF is higher in this set of data than previously reported in single center settings. With improved operator training and by selecting the better of two recordings for evaluation, qAF serves as a useful method for assessing changes in autofluorescence signal. Translational Relevance The qAF can be adopted as a clinical trial end point, but steps to counterbalance variability should be considered.
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Affiliation(s)
- Patty P. A. Dhooge
- Department of Ophthalmology, Radboud University Medical Center, Nijmegen, The Netherlands,Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Philipp T. Möller
- Department of Ophthalmology, University of Bonn, Bonn, Germany,GRADE Reading Center, Bonn, Germany
| | - Nils Meland
- SMERUD Medical Research International AS, Thunes vei 2, Oslo, Norway
| | - Katarina Stingl
- Univeristy Eye Hospital, Center for Ophthalmology, University of Tuebingen, Tuebingen, Germany
| | - Camiel J. F. Boon
- Department of Ophthalmology, Leiden University Medical Center, Leiden, The Netherlands,Department of Ophthalmology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | | | | | - Philipp Herrmann
- Department of Ophthalmology, University of Bonn, Bonn, Germany,Center for Rare Diseases Bonn (ZSEB), University of Bonn, Bonn, Germany
| | | | - Mario G. Fsadni
- Katairo GmbH, Kusterdingen, Germany,International Pharm-Med Ltd., Bramhall, UK
| | | | - Frank G. Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany,GRADE Reading Center, Bonn, Germany
| | - Carel B. Hoyng
- Department of Ophthalmology, Radboud University Medical Center, Nijmegen, The Netherlands,Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Steffen Schmitz-Valckenberg
- Department of Ophthalmology, University of Bonn, Bonn, Germany,GRADE Reading Center, Bonn, Germany,John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
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Dhooge PP, Möller PT, Boon CJ, Lotery AJ, Herrmann P, Battaglia Parodi M, Klein W, Fsadni MG, Wheeler-Schilling TH, Jungmann O, Müller H, Holz FG, Schmitz-Valckenberg S, Peters TM, Stingl K, Hoyng CB. The STArgardt Remofuscin Treatment Trial (STARTT): design and baseline characteristics of enrolled Stargardt patients. Open Res Eur 2022; 1:96. [PMID: 37645124 PMCID: PMC10445898 DOI: 10.12688/openreseurope.13872.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 08/31/2023]
Abstract
Background: This report describes the study design and baseline characteristics of patients with Stargardt disease (STGD1) enrolled in the STArgardt Remofuscin Treatment Trial (STARTT). Methods: In total, 87 patients with genetically confirmed STGD1 were randomized in a double-masked, placebo-controlled proof of concept trial to evaluate the safety and efficacy of 20 milligram oral remofuscin for 24 months. The primary outcome measure is change in mean quantitative autofluorescence value of an 8-segment ring centred on the fovea (qAF 8). Secondary efficacy variables are best corrected visual acuity (BCVA), low-luminance visual acuity (LLVA), mesopic microperimetry (mMP), spectral domain optical coherence tomography (SD-OCT), reading speed on Radner reading charts, and patient-reported visual function as assessed by the National Eye Institute Visual Functioning Questionnaire 25 (NEI VFQ-25) and Functional Reading Independence (FRI) Index. Results: Mean age of participants was 35±11 years with 49 (56%) female. Median qAF 8 value was 438 Units (range 210-729). Median BCVA and LLVA in decimal units were 0.50 (range 0.13-0.80) and 0.20 (range 0.06-0.63), respectively. The median of the mean retinal sensitivity with mMP was 20.4 dB (range 0.0-28.8). SD-OCT showed median central subfield retinal thickness of 142 µm (range 72-265) and median macular volume of 1.65 mm 3 (range 1.13-2.19). Compared to persons without vision impairment, both reading performance and patient-reported visual function were significantly lower (p<0.001, one sample t-test). Mean reading speed was 108±39 words/minute with logRAD-score of 0.45±0.28. Mean VFQ-25 composite score was 72±13. Mean FRI Index score 2.8±0.6. Conclusions: This trial design may serve as reference for future clinical trials as it explores the utility of qAF 8 as primary outcome measure. The baseline data represent the largest, multi-national, STGD1 cohort to date that underwent standardized qAF imaging, reading speed assessment and vision-related quality of life measures which all contribute to the characterization of STGD1. EudraCT registration: 2018-001496-20 (09/05/2019).
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Affiliation(s)
- Patty P.A. Dhooge
- Department of Ophthalmology, Radboud University Nijmegen Medical Centre, Nijmegen, 6500HB, The Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Nijmegen, 6525EN, The Netherlands
| | - Philipp T. Möller
- GRADE reading center, Bonn, 53127, Germany
- Department of Ophthalmology, University of Bonn, Bonn, 53127, Germany
| | - Camiel J.F. Boon
- Department of Ophthalmology, Amsterdam University Medical Center, Amsterdam, 1081HV, The Netherlands
- Department of Ophthalmology, Leiden University Medical Center, Leiden, 2333ZA, The Netherlands
| | - Andrew J. Lotery
- Faculty of Medicine, University of Southampton, Southampton, SO17 1BJ, UK
| | - Philipp Herrmann
- Department of Ophthalmology, University of Bonn, Bonn, 53127, Germany
- Center for Rare Diseases Bonn (ZSEB), University of Bonn, Bonn, 53113, Germany
| | | | | | - Mario G. Fsadni
- Katairo GmbH, Kusterdingen, 72127, Germany
- International Pharm-Med Ltd, Hemel Hempstead, HP1 1LD, UK
| | - Thomas H. Wheeler-Schilling
- University Eye Hospital, Center for Ophthalmology, Institute for Ophthalmic Research, University of Tübingen, Tübingen, 72076, Germany
| | - Oliver Jungmann
- Smerud Medical Research Germany GmbH, Mannheim, D-68161, Germany
| | - Hans Müller
- Smerud Medical Research Germany GmbH, Mannheim, D-68161, Germany
| | - Frank G. Holz
- GRADE reading center, Bonn, 53127, Germany
- Department of Ophthalmology, University of Bonn, Bonn, 53127, Germany
| | - Steffen Schmitz-Valckenberg
- GRADE reading center, Bonn, 53127, Germany
- Department of Ophthalmology, University of Bonn, Bonn, 53127, Germany
- John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, 84132, USA
| | - Tobias M. Peters
- University Eye Hospital, Center for Ophthalmology, Institute for Ophthalmic Research, University of Tübingen, Tübingen, 72076, Germany
| | - Katarina Stingl
- University Eye Hospital, Center for Ophthalmology, Institute for Ophthalmic Research, University of Tübingen, Tübingen, 72076, Germany
- Center for Rare Eye Diseases, University of Tübingen, Tübingen, 72076, Germany
| | - Carel B. Hoyng
- Department of Ophthalmology, Radboud University Nijmegen Medical Centre, Nijmegen, 6500HB, The Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Nijmegen, 6525EN, The Netherlands
| | - Soraprazan Consortium
- Department of Ophthalmology, Radboud University Nijmegen Medical Centre, Nijmegen, 6500HB, The Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Nijmegen, 6525EN, The Netherlands
- GRADE reading center, Bonn, 53127, Germany
- Department of Ophthalmology, University of Bonn, Bonn, 53127, Germany
- Department of Ophthalmology, Amsterdam University Medical Center, Amsterdam, 1081HV, The Netherlands
- Department of Ophthalmology, Leiden University Medical Center, Leiden, 2333ZA, The Netherlands
- Faculty of Medicine, University of Southampton, Southampton, SO17 1BJ, UK
- Center for Rare Diseases Bonn (ZSEB), University of Bonn, Bonn, 53113, Germany
- Department of Ophthalmology, Ospedale San Raffaele, Milan, 20132, Italy
- Katairo GmbH, Kusterdingen, 72127, Germany
- International Pharm-Med Ltd, Hemel Hempstead, HP1 1LD, UK
- University Eye Hospital, Center for Ophthalmology, Institute for Ophthalmic Research, University of Tübingen, Tübingen, 72076, Germany
- Smerud Medical Research Germany GmbH, Mannheim, D-68161, Germany
- John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, 84132, USA
- Center for Rare Eye Diseases, University of Tübingen, Tübingen, 72076, Germany
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Künzel SH, Lindner M, Sassen J, Möller PT, Goerdt L, Schmid M, Schmitz-Valckenberg S, Holz FG, Fleckenstein M, Pfau M. Association of Reading Performance in Geographic Atrophy Secondary to Age-Related Macular Degeneration With Visual Function and Structural Biomarkers. JAMA Ophthalmol 2021; 139:1191-1199. [PMID: 34591067 DOI: 10.1001/jamaophthalmol.2021.3826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance As a disabling and frequent disease, geographic atrophy secondary to age-related macular degeneration (AMD) constitutes an important study subject. Emerging clinical trials require suitable end points. The characterization and validation of reading performance as a functional outcome parameter is warranted. Objective To prospectively evaluate reading performance in geographic atrophy and to assess its association with established visual function assessments and structural biomarkers. Design, Setting, and Participants The noninterventional, prospective natural history Directional Spread in Geographic Atrophy study included patients with geographic atrophy secondary to AMD who were recruited at the University Hospital in Bonn, Germany. Participants were enrolled from June 2013 to June 2016. Analysis began December 2019 and ended January 2021. Main Outcomes and Measures Reading acuity and reading speed were assessed using Radner charts. Longitudinal fundus autofluorescence and infrared reflectance images were semiautomatically annotated for geographic atrophy, followed by extraction of shape-descriptive variables. Linear mixed-effects models were applied to investigate the association of those variables with reading performance. Results A total of 150 eyes of 85 participants were included in this study (median [IQR] age, 77.9 [72.4-82.1] years; 51 women [60%]; 34 men [40%]). Reading performance was impaired with a median (IQR) monocular reading acuity of 0.9 (0.4-1.3) logarithm of the reading acuity determination and a reading speed of 52.8 (0-123) words per minute. In the multivariable cross-sectional analysis, best-corrected visual acuity, area of geographic atrophy in the central Early Treatment Diabetic Retinopathy Study (ETDRS) subfield, classification of noncenter vs center-involving geographic atrophy, and area of geographic atrophy in the inner-right ETDRS subfield showed strongest associations with reading acuity (cross-validated R2for reading acuity = 0.69). Regarding reading speed, the most relevant variables were best-corrected visual acuity, low-luminance visual acuity, area of geographic atrophy in the central ETDRS subfield, in the inner-right ETDRS subfield, and in the inner-upper ETDRS subfield (R2 for reading speed = 0.67). In the longitudinal analysis, a similar prediction accuracy for reading performance was determined (R2 for reading acuity = 0.73; R2 for reading speed = 0.70). Prediction accuracy did not improve when follow-up time was added as an independent variable. Binocular reading performance did not differ from reading performance in the better-seeing eye. Conclusions and Relevance The association of reading acuity and speed with visual functional and structural biomarkers supports the validity of reading performance as a meaningful end point in clinical trials. These findings suggest that measures in clinical and low-vision care for patients with geographic atrophy should focus primarily on the better-seeing eye.
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Affiliation(s)
| | - Moritz Lindner
- Nuffield Laboratory of Ophthalmology, Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.,Institute for Physiology and Pathophysiology, Department of Neurophysiology, Philipps-University Marburg, Marburg, Germany
| | - Josua Sassen
- Institute for Numerical Simulation, University of Bonn, Bonn, Germany
| | | | - Lukas Goerdt
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, Medical Faculty, University of Bonn, Bonn, Germany
| | - Steffen Schmitz-Valckenberg
- Department of Ophthalmology, University of Bonn, Bonn, Germany.,John A. Moran Eye Center, University of Utah, Salt Lake City
| | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | | | - Maximilian Pfau
- Department of Ophthalmology, University of Bonn, Bonn, Germany.,Ophthalmic Genetics & Visual Function Branch, National Eye Institute, National Institutes of Health, Bethesda, Maryland
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Künzel SH, Möller PT, Lindner M, Goerdt L, Nadal J, Schmid M, Schmitz-Valckenberg S, Holz FG, Fleckenstein M, Pfau M. Determinants of Quality of Life in Geographic Atrophy Secondary to Age-Related Macular Degeneration. Invest Ophthalmol Vis Sci 2020; 61:63. [PMID: 32462198 PMCID: PMC7405807 DOI: 10.1167/iovs.61.5.63] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Purpose To longitudinally evaluate vision-related quality of life (VRQoL) in geographic atrophy (GA) secondary to age-related macular degeneration (AMD) and define its relation to visual function and structural biomarkers. Methods Patients with GA secondary to AMD were recruited in the context of the prospective, non-interventional, natural-history Directional Spread in Geographic-Atrophy study (NCT02051998). Fundus autofluorescence and infrared reflectance images were semi-automatically annotated for GA. Linear mixed-effects models were applied to investigate the association of putative determinants with the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ-25) VRQoL. Results A total of 87 patients with a mean age ± SD of 77.07 ± 7.49 years were included in the analysis. At baseline, median (IQR) best-corrected visual acuity (BCVA) was 0.3 (0.51) for the better eye and 0.89 (0.76) for the worse eye; 46% of the patients showed binocular and 25.3% monocular non-central GA. The VRQoL composite score was impaired: 69.96 (24.03). Sixty-six patients with a median of 2 (2) follow-up visits after 1.08 (0.78) years were examined longitudinally. Conclusions Vision-related quality of life is significantly impaired in patients with GA secondary to AMD. The cross-sectional and longitudinal association of VRQoL with visual functional and structural biomarkers supports the validity of the NEI VFQ-25 VRQoL.
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Pfau M, von der Emde L, Dysli C, Möller PT, Thiele S, Lindner M, Schmid M, Rubin DL, Fleckenstein M, Holz FG, Schmitz-Valckenberg S. Determinants of Cone and Rod Functions in Geographic Atrophy: AI-Based Structure-Function Correlation. Am J Ophthalmol 2020; 217:162-173. [PMID: 32289293 DOI: 10.1016/j.ajo.2020.04.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 11/18/2022]
Abstract
PURPOSE To investigate the association between retinal microstructure and cone and rod function in geographic atrophy (GA) secondary to age-related macular degeneration (AMD) by using artificial intelligence (AI) algorithms. DESIGN Prospective, observational case series. METHODS A total of 41 eyes of 41 patients (75.8 ± 8.4 years old; 22 females) from a tertiary referral hospital were included. Mesopic, dark-adapted (DA) cyan and red sensitivities were assessed by using fundus-controlled perimetry ("microperimetry"); and retinal microstructure was assessed by using spectral-domain optical-coherence-tomography (SD-OCT), fundus autofluorescence (FAF), and near-infrared-reflectance (IR) imaging. Layer thicknesses and intensities and FAF and IR intensities were extracted for each test point. The cross-validated mean absolute error (MAE) was evaluated for random forest-based predictions of retinal sensitivity with and without patient-specific training data and percentage of increased mean-squared error (%IncMSE) as measurement of feature importance. RESULTS Retinal sensitivity was predicted with a MAE of 4.64 dB for mesopic, 4.89 dB for DA cyan, and 4.40 dB for DA red testing in the absence of patient-specific data. Partial addition of patient-specific sensitivity data to the training sets decreased the MAE to 2.89 dB, 2.86 dB, and 2.77 dB. For all 3 types of testing, the outer nuclear layer thickness constituted the most important predictive feature (35.0, 42.22, and 53.74 %IncMSE). Spatially resolved mapping of "inferred sensitivity" revealed regions with differential degrees of mesopic and DA cyan sensitivity loss outside of the GA lesions. CONCLUSIONS "Inferred sensitivity" accurately reflected retinal function in patients with GA. Mapping of "inferred sensitivity" could facilitate monitoring of disease progression and serve as "quasi functional" surrogate outcome in clinical trials, especially in consideration of retinal regions beyond areas of GA.
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Affiliation(s)
- Maximilian Pfau
- Department of Ophthalmology, University of Bonn, Bonn, Germany; GRADE Reading Center, Bonn, Germany; Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | | | - Chantal Dysli
- Department of Ophthalmology, University of Bonn, Bonn, Germany; Departments of Ophthalmology and Clinical Research, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Philipp T Möller
- Department of Ophthalmology, University of Bonn, Bonn, Germany; GRADE Reading Center, Bonn, Germany
| | - Sarah Thiele
- Department of Ophthalmology, University of Bonn, Bonn, Germany; GRADE Reading Center, Bonn, Germany
| | - Moritz Lindner
- Department of Ophthalmology, University of Bonn, Bonn, Germany; Nuffield Laboratory of Ophthalmology, Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom; Department of Neurophysiology, Institute of Physiology and Pathophysiology, Philipps University, Marburg, Germany
| | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, Faculty of Medicine, University of Bonn, Bonn, Germany
| | - Daniel L Rubin
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Monika Fleckenstein
- Department of Ophthalmology, University of Bonn, Bonn, Germany; GRADE Reading Center, Bonn, Germany; John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA
| | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany; GRADE Reading Center, Bonn, Germany
| | - Steffen Schmitz-Valckenberg
- Department of Ophthalmology, University of Bonn, Bonn, Germany; GRADE Reading Center, Bonn, Germany; John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA.
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Pfau M, Möller PT, Künzel SH, von der Emde L, Lindner M, Thiele S, Dysli C, Nadal J, Schmid M, Schmitz-Valckenberg S, Holz FG, Fleckenstein M. Type 1 Choroidal Neovascularization Is Associated with Reduced Localized Progression of Atrophy in Age-Related Macular Degeneration. ACTA ACUST UNITED AC 2020; 4:238-248. [DOI: 10.1016/j.oret.2019.09.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 09/18/2019] [Accepted: 09/23/2019] [Indexed: 12/31/2022]
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von der Emde L, Thiele S, Pfau M, Nadal J, Meyer J, Möller PT, Schmid M, Fleckenstein M, Holz FG, Schmitz-Valckenberg S. Assessment of Exudative Activity of Choroidal Neovascularization in Age-Related Macular Degeneration by OCT Angiography. Ophthalmologica 2019; 243:120-128. [PMID: 31665719 DOI: 10.1159/000503609] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 09/23/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE Based on exudative activity, choroidal neovascularization (CNV) in age-related macular degeneration (AMD) can be classified as "active" aCNV, pretherapied "silent" sCNV (i.e., a treatment-free interval >12 weeks), or treatment-naïve "quiescent" qCNV. We evaluated the qualitative and quantitative optical coherence tomography angiography (OCTA) features of these CNV subgroups. METHODS The presence of small-caliber vessels, peripheral arcades, and a -perilesional OCTA signal attenuation as well as values for vessel length, density, and branching index were evaluated for each CNV network in a 6 × 6 mm OCTA scan pattern. RESULTS Fifty-one eyes of 51 patients with AMD (age 75.9 ± 7.5 years; 20 males [39.2%]) were included. The qCNV subgroup (n = 8) showed the highest prevalence of qualitative and quantitative values for OCTA activity criteria, reaching significance with regard to small-caliber vessels (p = 0.003), peripheral arcades (p = 0.039), vessel length (p = 0.020), and branching index (p < 0.001) when compared to the aCNV (n = 32) and sCNV (n = 11) subgroups. Qualitative criteria were inversely associated with the number of previous anti-VEGF injections (each p < 0.03), while quantitative metrics also suggested lower values. CONCLUSIONS These findings suggest that OCTA may be supportive in the phenotypical differentiation of CNV lesions secondary to AMD, while the assessed structural changes appeared to be more indicative of previously administered anti-VEGF therapy than current exudative activity.
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Affiliation(s)
| | - Sarah Thiele
- Department of Ophthalmology, University of Bonn, Bonn, Germany.,GRADE Reading Center, University of Bonn, Bonn, Germany
| | - Maximilian Pfau
- Department of Ophthalmology, University of Bonn, Bonn, Germany.,GRADE Reading Center, University of Bonn, Bonn, Germany
| | - Jennifer Nadal
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Johanna Meyer
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Philipp T Möller
- Department of Ophthalmology, University of Bonn, Bonn, Germany.,GRADE Reading Center, University of Bonn, Bonn, Germany
| | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Monika Fleckenstein
- Department of Ophthalmology, University of Bonn, Bonn, Germany.,GRADE Reading Center, University of Bonn, Bonn, Germany.,John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA
| | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany.,GRADE Reading Center, University of Bonn, Bonn, Germany
| | - Steffen Schmitz-Valckenberg
- Department of Ophthalmology, University of Bonn, Bonn, Germany, .,GRADE Reading Center, University of Bonn, Bonn, Germany, .,John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA,
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10
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Pfau M, von der Emde L, Dysli C, Thiele S, Möller PT, Lindner M, Nadal J, Schmid M, Schmitz-Valckenberg S, Holz FG, Fleckenstein M. Light Sensitivity Within Areas of Geographic Atrophy Secondary to Age-Related Macular Degeneration. ACTA ACUST UNITED AC 2019; 60:3992-4001. [DOI: 10.1167/iovs.19-27178] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Maximilian Pfau
- University of Bonn, Department of Ophthalmology, Bonn, Germany
- GRADE Reading Center, Bonn, Germany
| | | | - Chantal Dysli
- University of Bonn, Department of Ophthalmology, Bonn, Germany
- Department of Ophthalmology and Department of Clinical Research, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Sarah Thiele
- University of Bonn, Department of Ophthalmology, Bonn, Germany
- GRADE Reading Center, Bonn, Germany
| | - Philipp T. Möller
- University of Bonn, Department of Ophthalmology, Bonn, Germany
- GRADE Reading Center, Bonn, Germany
| | - Moritz Lindner
- The Nuffield Laboratory of Ophthalmology, Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Jennifer Nadal
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Germany
| | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Germany
| | | | - Frank G. Holz
- University of Bonn, Department of Ophthalmology, Bonn, Germany
- GRADE Reading Center, Bonn, Germany
| | - Monika Fleckenstein
- University of Bonn, Department of Ophthalmology, Bonn, Germany
- GRADE Reading Center, Bonn, Germany
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11
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von der Emde L, Pfau M, Dysli C, Thiele S, Möller PT, Lindner M, Schmid M, Fleckenstein M, Holz FG, Schmitz-Valckenberg S. Artificial intelligence for morphology-based function prediction in neovascular age-related macular degeneration. Sci Rep 2019; 9:11132. [PMID: 31366903 PMCID: PMC6668439 DOI: 10.1038/s41598-019-47565-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 07/19/2019] [Indexed: 11/09/2022] Open
Abstract
Spatially-resolved mapping of rod- and cone-function may facilitate monitoring of macular diseases and serve as a functional outcome parameter. However, mesopic and dark-adapted two-color fundus-controlled perimetry (FCP, also called "microperimetry") constitute laborious examinations. We have devised a machine-learning-based approach to predict mesopic and dark-adapted (DA) retinal sensitivity in eyes with neovascular age-related macular degeneration (nAMD). Extensive psychophysical testing and volumetric multimodal retinal imaging data were acquired including mesopic, DA red and DA cyan FCP, spectral-domain optical coherence tomography and confocal scanning laser ophthalmoscopy infrared reflectance and fundus autofluorescence imaging. With patient-wise leave-one-out cross-validation, we have been able to achieve prediction accuracies of (mean absolute error, MAE [95% CI]) 3.94 dB [3.38, 4.5] for mesopic, 4.93 dB [4.59, 5.27] for DA cyan and 4.02 dB [3.63, 4.42] for DA red testing. Partial addition of patient-specific sensitivity data decreased the cross-validated MAE to 2.8 dB [2.51, 3.09], 3.71 dB [3.46, 3.96], and 2.85 dB [2.62, 3.08]. The most important predictive feature was outer nuclear layer thickness. This artificial intelligence-based analysis strategy, termed "inferred sensitivity", herein, enables to estimate differential effects of retinal structural abnormalities on cone- and rod-function in nAMD, and may be used as quasi-functional surrogate endpoint in future clinical trials.
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Affiliation(s)
- Leon von der Emde
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany
| | - Maximilian Pfau
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany.,GRADE Reading Center, Ernst-Abbe-Str. 2, Bonn, Germany
| | - Chantal Dysli
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany.,Department of Ophthalmology and Department of Clinical Research, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Sarah Thiele
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany.,GRADE Reading Center, Ernst-Abbe-Str. 2, Bonn, Germany
| | - Philipp T Möller
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany.,GRADE Reading Center, Ernst-Abbe-Str. 2, Bonn, Germany
| | - Moritz Lindner
- The Nuffield Laboratory of Ophthalmology, Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, University of Bonn, Bonn, Germany
| | - Monika Fleckenstein
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany.,GRADE Reading Center, Ernst-Abbe-Str. 2, Bonn, Germany
| | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany.,GRADE Reading Center, Ernst-Abbe-Str. 2, Bonn, Germany
| | - Steffen Schmitz-Valckenberg
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany. .,GRADE Reading Center, Ernst-Abbe-Str. 2, Bonn, Germany.
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12
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Müller PL, Pfau M, Mauschitz MM, Möller PT, Birtel J, Chang P, Gliem M, Schmitz-Valckenberg S, Fleckenstein M, Holz FG, Herrmann P. Comparison of Green Versus Blue Fundus Autofluorescence in ABCA4-Related Retinopathy. Transl Vis Sci Technol 2018; 7:13. [PMID: 30279998 PMCID: PMC6166893 DOI: 10.1167/tvst.7.5.13] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/24/2018] [Indexed: 01/02/2023] Open
Abstract
Purpose To investigate the interreader and intermodality agreement for grading of retinal pigment epithelium (RPE) atrophy lesion size in ABCA4-related retinopathy using green (GAF) and blue fundus autofluorescence (BAF) imaging. Methods In this cross-sectional case series, 97 eyes of 49 patients with RPE atrophy secondary to ABCA4-related retinopathy underwent GAF- (518 nm excitation light) and BAF- (488 nm excitation light) imaging using confocal scanning laser ophthalmoscopy (Spectralis HRA, Heidelberg Engineering, Heidelberg, Germany). Lesions with definitely decreased autofluorescence (DDAF) and questionably decreased autofluorescence (QDAF) in GAF and BAF imaging were analyzed separately by five independent readers using semiautomated software (RegionFinder, Heidelberg Engineering). Intermodality and interreader agreements were assessed for the square-root lesion size, lesion perimeter, and circularity. Results GAF- and BAF-based measurements of DDAF and QDAF showed high intermodality and interreader agreement concerning square-root lesion size, as well as shape descriptive parameters (perimeter and circularity). Interreader agreement of square-root lesion size was slightly, hence not significantly higher for GAF-based grading ([95% coefficients of repeatability, intraclass correlation coefficient] DDAF: 0.215 mm, 0.997; QDAF: 0.712 mm, 0.981) compared to BAF-based grading (DDAF: 0.232 mm, 0.997; QDAF: 0.764 mm, 0.978). However, DDAF-measurements revealed distinctly more reproducible results than QDAF-measurements. Foveal sparing did not interfere with intermodality agreement. Conclusions Both GAF- and BAF-based quantification of RPE atrophy showed very reliable results with possible superiority of GAF in the context of less energetic excitation light. Translational Relevance The high interreader agreement qualifies the use of DDAF progression in GAF and BAF imaging as potential morphologic outcome measure for interventional clinical trials and disease monitoring.
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Affiliation(s)
- Philipp L Müller
- Department of Ophthalmology, University of Bonn, Bonn, Germany.,Center for Rare Diseases, University of Bonn, Bonn, Germany
| | - Maximilian Pfau
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | | | | | - Johannes Birtel
- Department of Ophthalmology, University of Bonn, Bonn, Germany.,Center for Rare Diseases, University of Bonn, Bonn, Germany
| | - Petrus Chang
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Martin Gliem
- Department of Ophthalmology, University of Bonn, Bonn, Germany.,Center for Rare Diseases, University of Bonn, Bonn, Germany.,Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany.,Center for Rare Diseases, University of Bonn, Bonn, Germany
| | - Philipp Herrmann
- Department of Ophthalmology, University of Bonn, Bonn, Germany.,Center for Rare Diseases, University of Bonn, Bonn, Germany
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13
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Müller PL, Pfau M, Möller PT, Nadal J, Schmid M, Lindner M, de Sisternes L, Stöhr H, Weber BHF, Neuhaus C, Herrmann P, Schmitz-Valckenberg S, Holz FG, Fleckenstein M. Choroidal Flow Signal in Late-Onset Stargardt Disease and Age-Related Macular Degeneration: An OCT-Angiography Study. ACTA ACUST UNITED AC 2018; 59:AMD122-AMD131. [DOI: 10.1167/iovs.18-23819] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Philipp L. Müller
- Department of Ophthalmology, University of Bonn, Bonn, Germany
- Center for Rare Diseases, University of Bonn, Bonn, Germany
| | - Maximilian Pfau
- Department of Ophthalmology, University of Bonn, Bonn, Germany
- GRADE Reading Center, Bonn, Germany
| | - Philipp T. Möller
- Department of Ophthalmology, University of Bonn, Bonn, Germany
- GRADE Reading Center, Bonn, Germany
| | - Jennifer Nadal
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Moritz Lindner
- Department of Ophthalmology, University of Bonn, Bonn, Germany
- The Nuffield Laboratory of Ophthalmology, Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Luis de Sisternes
- Department of Radiology, Stanford University, Stanford, California, United States
- Carl Zeiss Meditec, Inc., Dublin, California, United States
| | - Heidi Stöhr
- Institute of Human Genetics, University of Regensburg, Regensburg, Germany
| | | | | | - Philipp Herrmann
- Department of Ophthalmology, University of Bonn, Bonn, Germany
- Center for Rare Diseases, University of Bonn, Bonn, Germany
| | | | - Frank G. Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany
- Center for Rare Diseases, University of Bonn, Bonn, Germany
- GRADE Reading Center, Bonn, Germany
| | - Monika Fleckenstein
- Department of Ophthalmology, University of Bonn, Bonn, Germany
- GRADE Reading Center, Bonn, Germany
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14
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von der Emde L, Pfau M, Thiele S, Möller PT, Hassenrik R, Fleckenstein M, Holz FG, Schmitz-Valckenberg S. Mesopic and Dark-Adapted Two-Color Fundus-Controlled Perimetry in Choroidal Neovascularization Secondary to Age-Related Macular Degeneration. Transl Vis Sci Technol 2018; 8:7. [PMID: 30637177 PMCID: PMC6327348 DOI: 10.1167/tvst.8.1.7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/17/2018] [Indexed: 01/14/2023] Open
Abstract
Purpose To determine the retest variability of mesopic and two-color dark-adapted (DA) fundus-controlled perimetry (FCP), to evaluate the predictive value of patient reliability indices, and to analyze the extent of impairment of rod- and cone function in neovascular age-related macular degeneration (nAMD). Methods A total of 50 eyes of 50 patients with nAMD (mean age, 76.1 years) and 70 eyes of 70 age-similar normal subjects underwent multimodal imaging as well as mesopic and DA two-color perimetry using the S-MAIA device. A subset of patients (n = 28) underwent duplicate testing for retest reliability assessment. Mixed models were used for analysis of the hierarchical data. Results In eyes with nAMD, the coefficient of repeatability was (mean ± standard deviation [SD]) 5.99 ± 1.55 dB for mesopic, 6.14 ± 2.19 dB for DA cyan, and 6.06 ± 1.09 dB for DA red testing. “Patient reliability indices” explained 55%, 54.2%, and 64.2% of the variance in retest variability. The mean sensitivity loss was greater for DA cyan compared to DA red testing (cyan-red differences [mean ± SD] −2.63 ± 3.87 dB, P < 0.001). Conclusions The relatively greater degree of DA cyan versus DA red sensitivity loss indicates preferential rod vulnerability in nAMD, and qualifies rod function-based outcomes measures as potential sensitive and early markers of treatment response in nAMD. Translational Relevance The S-MAIA allows reliable testing of mesopic, DA cyan, and DA red sensitivity in patients with nAMD. Patient reliability indices may serve as eligibility criteria for clinical trials to identify patients with adequate retest reliability.
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Affiliation(s)
- Leon von der Emde
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany
| | - Maximilian Pfau
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany.,GRADE Reading Center, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany
| | - Sarah Thiele
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany.,GRADE Reading Center, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany
| | - Philipp T Möller
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany.,GRADE Reading Center, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany
| | - Ruth Hassenrik
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany
| | - Monika Fleckenstein
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany.,GRADE Reading Center, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany
| | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany.,GRADE Reading Center, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany
| | - Steffen Schmitz-Valckenberg
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany.,GRADE Reading Center, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany
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