Psychological and cognitive determinants of vision function in age-related macular degeneration

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

BACKGROUND/OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Identification of appropriate tools to gauge brain functions in a clinical setup of a developing country: A pilot study

Objective

To identify the most appropriate tools to measure functions of the brain that can be utilized in the clinical setups of developing countries.

Methods

This qualitative research with a three-step approach was carried out from January 2022 to May 2022 at the Institute of Basic Medical Sciences, Khyber Medical University, Pakistan. Firstly, literature was searched to identify main brain faculties, then interviews were conducted with regional field experts to identify appropriate scales for the selected functions. Lastly a rubric was filled using interview transcripts and literature.

Results

The identified functions were vision, hearing, cognition, motor and emotions. Based on the rubric the best tests were visual fields (17/24), pure tone audiometry (16/24), Mini-Mental State Exam (20/24), Trait Emotional Intelligence Questionnaire (18/24), Romberg's test (19/24) and Manual Muscle Testing (18/24).

Conclusion

The clinicians in developing countries can utilize the visual fields, pure tone audiometry, Mini-Mental State Exam, Trait Emotional Intelligence Questionnaire, Romberg's test and Manual Muscle Testing for most efficient, feasible, accurate and cost-effective measurement of brain functions.

Anxiety in Patients with Neovascular Age-related Macular Degeneration

PURPOSE

The main objective of the study is to investigate the prevalence of anxiety in patients with neovascular age-related macular degeneration (nAMD).

METHODS

A retrospective cross-sectional study of 3 304 nAMD patients and 16 515 age- and gender-matched controls. The proportions of patients with anxiety were compared between the groups using univariate analyses and a multivariate logistic regression model. Proportion of anxiety in patients with nAMD was compared with the proportion of anxiety in controls, matched for age and gender. Data was obtained from the largest health maintenance organization in Israel (Clalit Health Services) with 4 200 000 members.

RESULTS

The mean age of patients was 79.7 years; 54.8% were females; Anxiety was more common in patients with nAMD (13.2%) compared to the control group (10.2%) (OR 1.3; 95%CI 1.2-1.5). Multivariate logistic regression analysis revealed a significant association between anxiety and nAMD (OR 1.3; 95% CI: 1.2-1.5), adjusted for age, gender, and socio-economic status.

CONCLUSION

Our study demonstrated that anxiety is more common in patients with nAMD compared to a control group. Physicians treating patients with nAMD should be aware of this association, in order to provide appropriate care for the anxiety associated with nAMD.

Vision impairment and cognitive decline among older adults: a systematic review

OBJECTIVES

There has been increasing epidemiological research examining the association between vision impairment (VI) and cognitive impairment and how poor vision may be a modifiable risk factor for cognitive decline. The objective of this systematic review is to synthesise the published literature on the association of VI with cognitive decline, cognitive impairment or dementia, to aid the development of interventions and guide public policies pertaining to the relationship between vision and cognition.

METHODS

A literature search was performed with Embase, Medline and Cochrane library databases from inception to March 2020, and included abstracts and articles published in peer-reviewed journals in English. Our inclusion criteria included publications that contained subjective/objective measures of vision and cognition, or a diagnosis of VI, cognitive impairment or dementia. Longitudinal or cross-sectional studies with ≥100 participants aged >50 years were included. The search identified 11 805 articles whose abstracts underwent screening by three teams of study authors. Data abstraction and quality assessment using the Effective Public Health Practice Project Quality Assessment Tool were performed by one author (NN). 10% of the articles underwent abstraction and appraisal by a second author (LA/VV), results were compared between both and were in agreement.

RESULTS

110 full-text articles were selected for data extraction, of which 53 were cross-sectional, 43 longitudinal and 14 were case-control studies. The mean age of participants was 73.0 years (range 50-93.1). Ninety-one (83%) of these studies reported that VI was associated with cognitive impairment.

CONCLUSION

Our systematic review indicates that a majority of studies examining the vision-cognition relationship report that VI is associated with more cognitive decline, cognitive impairment or dementia among older adults. This synthesis supports the need for additional research to understand the mechanisms underlying the association between VI and cognitive impairment and to test interventions that mitigate the cognitive consequences of VI.

Increased Near Activities Function Associated With Increased Glaucoma Medication Adherence Among Support, Educate, Empower (SEE) Participants

PRECIS

Higher levels of near vision-related quality of life (VRQoL) were associated with higher adherence to glaucoma medications after adjusting for important confounding variables among participants in the Support, Educate, Empower (SEE) personalized glaucoma coaching pilot study.

PURPOSE

To investigate the association between VRQoL and glaucoma medication adherence.

MATERIALS AND METHODS

Subjects were recruited for the SEE program, a prospective noncontrolled cohort study examining the impact of a personalized coaching program on glaucoma medication adherence. Glaucoma patients seen at the University of Michigan over 40 years old, taking ≥1 glaucoma medication, and self-reported poor adherence on 2 validated scales were recruited. Demographic details and VRQoL using the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) were collected. Participants' medication use for each prescribed glaucoma medication was captured electronically using a medication events monitoring system. The association between VRQoL and medication adherence was assessed with Pearson correlation coefficient (r) and linear regression.

RESULTS

Among the 95 eligible participants 49.5% were female, 55.3% were Caucasian, and mean age (±SD) was 63.8±10.5 years. Mean adherence to glaucoma medication was 73.8%±21.0%. Mean NEI VFQ-25 composite score was 81.6±14.5. Better medication adherence was significantly and positively correlated with better functioning in domains of ocular pain (r=0.20, P=0.048), near activities (r=0.29, P=0.004), and role difficulties (r=0.22, P=0.036). Linear regression models adjusting for known correlates of medication adherence (age, sex, race, income), showed a 10-unit increase in self-perceived near activities function was associated with a 2.2% increase in medication adherence (95% confidence interval, 1.0%-5.4%; P=0.0056).

CONCLUSION

Better self-perceived near activities function was associated with increased glaucoma medication adherence.

Healthcare Resource Utilization and Costs in Patients with Geographic Atrophy Secondary to Age-Related Macular Degeneration

Purpose

Geographic atrophy (GA) is an advanced form of nonexudative age-related macular degeneration (AMD) that lacks treatment options. With considerable interpatient variability in the rate of GA progression due to lesion characteristics, information characterizing the disease burden is limited. The aim of this study was to describe the healthcare resource utilization (HCRU) and costs associated with increasing severity levels of GA.

Patients and Methods

A retrospective analysis was conducted using claims data from IQVIA’s PharMetrics Plus database. Patients with a prevalent GA diagnosis were identified between October 1, 2016 and June 30, 2017 and classified by disease severity and laterality. Disease-specific HCRU and costs by disease severity were assessed during the 12-month follow-up period, with multivariable analyses performed adjusting for baseline characteristics.

Results

A total of 28,773 GA cases were identified (mean age = 68.7; 58.5% female), of which 24% and 76% had unilateral and bilateral GA, respectively, with varying levels of recorded severity (in increasing order): early or intermediate (EI) AMD, GA without subfoveal involvement (GAwoSF), and GA with subfoveal involvement (GAwSF). Patients with greater baseline severity in the bilateral group had a significantly higher number of outpatient (OP) visits per year (1.98 EI AMD; 2.57 for GAwoSF; 2.63 for GAwSF). Increasing disease severity was associated with higher patient-related costs in the outpatient setting (mean [SD] of $82 [$157], $110 [$559] for unilateral EI AMD and GAwSF, respectively, and $56 [$94], $64 [$97], $59 [$85] for bilateral EI AMD, GAwoSF, GAwSF, respectively). Similarly, higher payer-related costs were seen in patients with bilateral GAwSF compared to bilateral EI AMD (mean [SD] $280 [$325]; $198 [$262]).

Conclusion

Study findings demonstrate that patients, with more severe GA at baseline, experience greater HCRU and costs in the outpatient setting. Further research should explore specific contributing factors to the long-term economic burden of GA.

Quality of life: Investigating the impact of two major mental disorders, anxiety and depression, in patients with age-related macular degeneration

Purpose:

The purpose of this study was to investigate the impact on the quality of life of patients with age-related macular degeneration (AMD) in relation to common mental disorders, namely anxiety and depression, and determine specific factors (e.g., thoughts/feelings, sociodemographic characteristics) that may be used to refer such patients to psychiatrists.

Materials–Methods:

To classify the patients into different categories, regarding the development of the mental disorders under consideration, the “Hospital Anxiety and Depression Scale” (HADS) has been utilized. The main statistical methodologies applied are classification and regression trees (CART) techniques and logistic regression. For the purposes of the aforementioned statistical analysis, the R software package has been used.

Results:

Both depression and anxiety scores varied considerably across visual acuity (VA) severity. Patients with severe visual acuity problems tend to have also higher HADS scores. Women were more likely to be affected by depression; sociodemographic factors did not have any significant effect. According to the performed CART analysis, responses to two HADS items (namely, “I can enjoy a good book or radio or television program” and “I have lost interest in my appearance”) identified the vast majority of severely to moderately depressed patients. Furthermore, the level of VA severity was found as a main driver for diagnosing an AMD patient with depression.

Conclusions:

VA impairment (or decline) severity level was found to be the main factor associated with depression in patients with AMD. Moreover, specific thoughts/feelings present in patients with AMD have been found as significant regarding the level of their mental disorders under consideration and could be asked by the ophthalmologist to refer (or not) them to psychiatrists.

Psychosocial assessment of potential retinal prosthesis trial participants

BACKGROUND

As the field of retinal prostheses advances, volunteers are required for device trials, and optimal participant recruitment is vital for intervention success. The aims of this study were: (i) to select tests that assess the psychosocial aspects of visual impairment and develop a psychosocial assessment protocol for persons who may be eligible for participation in retinal prostheses trials; (ii) to investigate correlations between these tests; and (iii) to determine associations between psychosocial factors and a person's interest in participating in a retinal prosthesis (bionic eye) trial.

METHODS

Cross-sectional study of 72 adults with advanced retinal degeneration. Questionnaire assessments included personality, cognitive ability, social-support, self-efficacy, coping, optimism, depression, and quality of life (Impact of Vision Impairment Profile ([IVI], and Vision and Quality of Life Index [VisQoL]). Level of interest in a retinal prosthesis was also evaluated.

RESULTS

All questionnaires were completed without floor or ceiling effects and with minimal respondent burden. Depression correlated with decreased quality of life (rho = -0.37 and 0.40, p < 0.001 for IVI and VisQoL, respectively). Together, depression, gender and vision-specific coping explained 35.2 per cent of variance in IVI quality of life (p < 0.001). Forty-nine per cent of participants were interested in a retinal prosthesis now and 77 per cent in the future. Although the personality trait of 'openness' was somewhat predictive of interest in retinal prostheses (odds ratio 0.78, 95% CI 0.62-0.97), neither severity of vision impairment nor any of the psychosocial measures were strong predictors.

CONCLUSIONS

Several existing psychosocial questionnaires can be used for patients with advanced retinal degeneration and may be useful in exploring suitability for a retinal prosthesis or evaluating outcomes. However, the questionnaires used in this study were not good predictors of whether or not a person might be interested in a retinal prosthesis.

Sensory-Cognitive Interactions in Older Adults

The objective of this study was regarding sensory and cognitive interactions in older adults published since 2009, the approximate date of the most recent reviews on this topic. After an electronic database search of articles published in English since 2009 on measures of hearing and cognition or vision and cognition in older adults, a total of 437 articles were identified. Screening by title and abstract for appropriateness of topic and for articles presenting original research in peer-reviewed journals reduced the final number of articles reviewed to 34. These articles were qualitatively evaluated and synthesized with the existing knowledge base. Additional evidence has been obtained since 2009 associating declines in vision, hearing, or both with declines in cognition among older adults. The observed sensory-cognitive associations are generally stronger when more than one sensory domain is measured and when the sensory measures involve more than simple threshold sensitivity. Evidence continues to accumulate supporting a link between decline in sensory function and cognitive decline in older adults.

The Preferred Retinal Locus Used to Watch Videos

Purpose

Eccentric viewing is a common strategy used by people with central vision loss (CVL) to direct the eye such that the image falls onto functioning peripheral retina, known as the preferred retinal locus (PRL). It has been long acknowledged that we do not know whether the PRL used in a fixation test is also used when performing tasks. We present an innovative method to determine whether the same PRL observed during a fixation task was used to watch videos and whether poor resolution affects gaze location.

Methods

The gaze of a group of 60 normal vision (NV) observers was used to define a democratic center of interest (COI) of video clips from movies and television. For each CVL participant (N = 20), we computed the gaze offsets from the COI across the video clips. The distribution of gaze offsets of the NV participants was used to define the limits of NV behavior. If the gaze offset was within this 95% degree confidence interval, we presumed that the same PRL was used for fixation and video watching. Another 15 NV participants watched the video clips with various levels of defocus blur.

Results

CVL participants had wider gaze-offset distributions than NV participants (P < 0.001). Gaze offsets of 18/20 CVL participants were outside the NV confidence interval. Further, none of the 15 NV participants watching the same videos with spherical defocus blur had a gaze offset that was decentered (outside the NV confidence interval), suggesting that resolution was not the problem.

Conclusions

This indicates that many CVL participants were using a PRL to view videos that differed from that found with a fixation task and that it was not caused by poor resolution alone. The relationship between these locations needs further investigation.

Multivariable Regression Model of the EuroQol 5-Dimension Questionnaire in Patients Seeking Outpatient Low Vision Rehabilitation

PURPOSE

To understand the source of between-person variance in baseline health utilities estimated from EuroQol 5-dimension questionnaire (EQ-5D) responses of a representative sample of the US low vision outpatient population prior to rehabilitation.

METHODS

A prospective, observational study of 779 new low vision patients at 28 clinic centers in the US. The EQ-5D, Activity Inventory (AI), Telephone Interview for Cognitive Status (TICS), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) physical functioning component, and Geriatric Depression Scale (GDS) were administered by telephone interview prior to rehabilitation. EQ-5D responses were transformed into health utilities, which served as the dependent variable in all analyses. Data were then analyzed to determine how much overall visual ability, functional domains of visual ability, and comorbidities (e.g. physical functioning, depression, cognition) independently contribute to the EQ-5D-based health utility index.

RESULTS

Multivariable regression analyses showed that the GDS and SF-36 physical account for nearly 40% of the variance observed in health utilities estimated from EQ-5D responses of low vision patients. Age was also a significant predictor of health utilities, but accounted for very little variance. None of the other variables were significant predictors.

CONCLUSIONS

Health utilities of low vision patients estimated from the EQ-5D primarily are associated with comorbid factors that are not likely to be responsive to low vision rehabilitation, thereby rendering the EQ-5D an unsuitable outcome measure for this population. However, because the EQ-5D is responsive to comorbid states, it could be a useful tool for evaluating the impact of comorbidities on low vision patient quality of life.

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

OBJECTIVES

To review systematically the evidence of age-related macular degeneration (AMD) affecting real-world visual ability and quality of life (QoL). To explore trends in specific topics within this body of the literature.

DESIGN

Systematic review.

METHODS

A systematic literature search was carried out using MEDLINE, EMBASE, CINAHL, PsycINFO, PsychARTICLES and Health and Psychosocial Instruments for articles published up to January 2015 for studies including people diagnosed with AMD, assessing real-world visual ability or QoL as an outcome. Two researchers screened studies for eligibility. Details of eligible studies including study design, characteristics of study population and outcomes measured were recorded in a data extraction table. All included studies underwent quality appraisal using the Mixed Methods Appraisal Tool 2011 Version (MMAT).

RESULTS

From 5284 studies, 123 were eligible for inclusion. A range of approaches were identified, including performance-based methods, quantitative and qualitative patient-reported outcome measures (PROMs). AMD negatively affects tasks including mobility, face recognition, perception of scenes, computer use, meal preparation, shopping, cleaning, watching TV, reading, driving and, in some cases, self-care. There is evidence for higher rates of depression among people with AMD than among community dwelling elderly. A number of adaptation strategies have been associated with AMD of varying duration. Much of the research fails to report the type of AMD studied (59% of included studies) or the duration of disease in participants (74%). Of those that do report type studied, the breakdown is as follows: wet AMD 20%, dry AMD 4% and both types 17%.

CONCLUSIONS

There are many publications highlighting the negative effects of AMD in various domains of life. Future research should focus on delivering some of this research knowledge into patient management and clinical trials and differentiating between the types of AMD.

Risk Factors for Poor Quality of Life among Patients with Age-Related Macular Degeneration

PURPOSE

The purpose of this study was to evaluate the quality of life in patients with age-related macular degeneration (AMD) and compare it with that of healthy controls. Additionally, our study aims to investigate the possible risk factors for poor quality of life in AMD patients.

METHODS

Participants in the study were 114 patients with AMD, 63 male and 51 female, mean-aged 76.5 ± 6.1 years. Demographic data, lifestyle factors, and medical history were recorded. All patients underwent a routine examination for AMD, including best-corrected visual acuity measurement, dilated fundoscopy and optical coherence tomography, and completed three questionnaires assessing quality of life (SF-36, EQ-5D, NEI VFQ-25). In addition, 100 controls, adjusted for gender and age, were included in the study. Risk factors for quality of life in AMD patients were investigated. Univariate analysis was performed using SPSS 22.0.

RESULTS

Patients with AMD scored lower in vision- and health-related quality-of-life questionnaires compared to controls. Risk factors associated with quality of life in patients with AMD were found to be the female gender, alcohol consumption, the presence of hypertension, diabetes mellitus, cardiovascular diseases, myosceletal problems, migraine, anxiety/depression, subretinal or intraretinal fluid, pigment epithelium detachment, previous treatment for AMD, visual acuity, the stage of the disease, and the integrity of the ellipsoid zone.

CONCLUSION

Patients with AMD presented lower quality of life in comparison with controls. Potential risk factors should be taken into account and clinicians should thus focus on the most vulnerable subgroups.

Sporadic visual acuity loss in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT)

PURPOSE

To evaluate transient, large visual acuity (VA) decreases, termed sporadic vision loss, during anti-vascular endothelial growth factor treatment for neovascular age-related macular degeneration (AMD).

DESIGN

Cohort within a randomized clinical trial.

METHODS

setting: Comparison of Age-Related Macular Degeneration Treatments Trials (CATT). study population: Total of 1185 CATT patients. main outcome measures: Incidence of sporadic vision loss and odds ratio (OR) for association with patient and ocular factors. Sporadic vision loss was a decline of ≥15 letters from the previous visit, followed by a return at the next visit to no more than 5 letters worse than the visit before the VA loss.

RESULTS

There were 143 sporadic vision loss events in 122 of 1185 patients (10.3%). Mean VA at 2 years for those with and without sporadic vision loss was 58.5 (∼20/63) and 68.4 (∼20/40) letters, respectively (P < .001). Among patients treated pro re nata, no injection was given for 27.6% (27/98) of sporadic vision loss events. Multivariate analysis demonstrated that baseline predictors for sporadic vision loss included worse baseline VA (OR 2.92, 95% confidence interval [CI]:1.65-5.17 for ≤20/200 compared with ≥20/40), scar (OR 2.21, 95% CI:1.22-4.01), intraretinal foveal fluid on optical coherence tomography (OR 1.80, 95% CI:1.11-2.91), and medical history of anxiety (OR 1.90, 95% CI:1.12-3.24) and syncope (OR 2.75, 95% CI:1.45-5.22). Refraction decreased the likelihood of sporadic vision loss (OR 0.62, 95%CI: 0.42-0.91).

CONCLUSIONS

Approximately 10% of CATT patients had sporadic vision loss. Baseline predictors included AMD-related factors and factors independent of AMD. These data are relevant for clinicians in practice and those involved in clinical trials.

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

Introduction

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

Methods

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

Results

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

Implications for practitioners

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

The Vision-Specific Optimization in Primary and Secondary Control (OPS) Scale

OBJECTIVE

To successfully address the challenges of age-related visual impairment in rehabilitation and health care settings, it is crucial to gain a better understanding of the psychological and behavioral adaptations that occur in these populations. The purpose of this study was to modify the Optimization in Primary Secondary Control Scale (OPS) (Heckhausen Schulz and Wrosch 1999) to assess the utilization of lifespan control strategies among older adults with visual impairment.

METHOD

The Optimization in Primary and Secondary Control Scale (OPS) (Heckhausen et al. 1999) was used to develop a vision-specific version of this measure (i.e., VIS-OPS). The VIS-OPS was administered to older adults with recent vision loss (N = 364; Mean age = 82.9 years). Theory-driven confirmatory factor analysis was used to help refine the instrument and confirm the scale's four-factor structure.

RESULTS

Items were removed from three of the four VIS-OPS subscales due to low squared-multiple correlations and poor model fit. Inter-item reliabilities for the resultant subscales ranged from 0.61 to 0.72. The final four-factor model fit the data well (RMSEA = .06, 90% CI .05--.06), with all items loading significantly on their associated factors (i.e. subscales). Correlational analyses provided criterion-related validity for the VIS-OPS with disability and psychosocial functioning measures in the expected directions.

CONCLUSIONS

The VIS-OPS will allow researchers to more systematically and precisely measure control strategy use in reference to specific challenges associated with visual impairment, and may serve as a model for examining control strategy use in the context of other disabilities.

A low-vision rehabilitation program for patients with mild cognitive deficits

IMPORTANCE

We are unaware of any standardized protocols within low-vision rehabilitation (LVR) to address cognitive impairment.

OBJECTIVE

To design and pilot-test an LVR program for patients with macular disease and cognitive deficits.

DESIGN

The Memory or Reasoning Enhanced Low Vision Rehabilitation (MORE-LVR) program was created by a team representing optometry, occupational therapy, ophthalmology, neuropsychology, and geriatrics. This pilot study compares outcomes before and after participation in the MORE-LVR program.

SETTING

Eligible patients were recruited from an LVR clinic from October 1, 2010, through March 31, 2011.

PARTICIPANTS

Twelve patients completed the intervention, and 11 companions attended at least 1 training session.

INTERVENTION

Key components of the MORE-LVR intervention are as follows: (1) repetitive training with a therapist twice weekly during a 6-week period, (2) simplified training experience addressing no more than 3 individualized goals in a minimally distracting environment, and (3) involvement of an informal companion (friend or family member).

MAIN OUTCOME MEASURES

Version 2000 National Eye Institute Vision Function Questionnaire-25; timed performance measures, Telephone Interview for Cognitive Status-modified(TICS-m), Logical Memory tests, satisfaction with activities of daily living, and goal attainment scales.

RESULTS

Twelve patients without dementia (mean age, 84.5 years; 75% female) who screened positive for cognitive deficits completed the MORE-LVR program. Participants demonstrated improved mean (SD) scores on the National Eye Institute's Visual Function Questionnaire-25 composite score (47.2 [16.3] to 54.8 [13.8], P = .01) and near-activities score (21.5 [14.0] to 41.0 [23.1], P = .02), timed performance measures (writing a grocery list [P = .03], filling in a crossword puzzle answer [P = .003]), a score indicating satisfaction with independence (P = .05), and logical memory (P = .02). All patients and companions reported progress toward at least 1 individualized goal; more than 70% reported progress toward all 3 goals.

CONCLUSIONS AND RELEVANCE

This pilot study demonstrates feasibility of an LVR program for patients with macular disease and mild cognitive deficits. Participants demonstrated improvements in vision-related function and cognitive measures and expressed high satisfaction. Future work is needed to determine whether MORE-LVR is superior to usual outpatient LVR for persons with coexisting visual and cognitive impairments.

Real-world variability in ranibizumab treatment and associated clinical, quality of life, and safety outcomes over 24 months in patients with neovascular age-related macular degeneration: the HELIOS study

INTRODUCTION

The aim of this study was to examine ranibizumab treatment patterns in "real-world" practice and clinical settings, as well as to assess quality of life outcomes over a 24-month period.

MATERIALS AND METHODS

This was a prospective, observational, multicenter, open-label study of 0.5 mg of ranibizumab administered intravitreally. Patients were followed over 24 ± 3 months with intermediate data points at 6 ± 2 months and 12 ± 2 months, and a limited data point at 2.5 ± 1 month that coincided with the end of the loading phase. Outcomes included visual acuity (Early Treatment Diabetic Retinopathy Study), visual function (National Eye Institute Visual Function Questionnaire-25 [NEI VFQ-25]), quality of life (Health Utilities Index Mark III [HUI3]), and safety.

RESULTS

A total of 267 patients with wet age-related macular degeneration (mean ± standard deviation [SD] age = 78.5 ± 7.3 years; 62.4% were female; 34.5% with dual eye involvement; 74.9% were treatment-naïve) were treated (309 eyes were treated). The mean ± SD Early Treatment Diabetic Retinopathy Study score at baseline was 56.3 ± 14.3 letters. The mean ± SD number of injections over 24 months was 7.6 ± 4.1, including 2.5 ± 0.7 and 5.9 ± 3.6 during the loading and maintenance phases, respectively, with corresponding treatment intervals of 4.8 ± 1.4 weeks and 11.5 ± 9.5 weeks, respectively. Improvements in visual acuity over baseline were reached at 2.5 months and maintained at 6 months (both P < 0.0001). The mean visual acuity increase over baseline at 12 months was not significant (P = 0.08); the decline over baseline at 24 months statistically significant (P = 0.02). Overall, 94.3% of patients showed stable or improved disease at 6 months and 81.5% of patients showed stable or improved disease at 24 months. At 6 months, improvements over baseline were significant for VFQ-25 (P = 0.03) and HUI3 (P = 0.02), but not at 12 months and 24 months. Improvements in VFQ-25 and HUI3 were maintained at 24 months in 38% and 34% of patients, respectively. In total 78 serious adverse events were reported in 40 patients and 77 nonserious adverse events in 34 patients. Nine serious adverse events and nine nonserious adverse events in 14 patients were suspected to be related to ranibizumab treatment.

CONCLUSION

The "real-world" clinical effectiveness of ranibizumab was evidenced by the initial improvements over baseline in visual acuity and quality of life, as well as the maintenance of these outcomes at baseline levels at 24 months, and this was observed under variable treatment conditions. The findings underscore the need for individualized treatment with regular monitoring to achieve optimal vision and quality of life outcomes.

Depression in the elderly with visual impairment and its association with quality of life

Background

Visual impairment is more prevalent in the elderly and depression is common in this population. Although many studies have investigated depression or quality of life (QOL) in older adults with visual impairment, few have looked at the association between these two concepts for this population. The aim of this systematized review was to describe the association between depression and QOL in older adults with visual impairment.

Methods

A search was done using multiple electronic databases for studies addressing the relationship between QOL and depression in elders with visual impairment. The concept of QOL was divided into two different approaches, ie, QOL as achievement and QOL as subjective well-being. Comparison of QOL scores between participants with and without depression (Cohen’s d) and correlations between depression and QOL (Pearson’s r) were examined.

Results

Thirteen studies reported in 18 articles were included in the review. Nearly all of the studies revealed that better QOL was moderately to strongly correlated with less severe depressive symptoms (r = 0.22–0.68 for QOL as achievement; r = 0.68 and 0.72 for QOL as subjective well-being). Effect sizes for the QOL differences between the groups with and without depression ranged from small to large (d = 0.17 to 0.95 for QOL as achievement; no data for QOL as subjective well-being).

Conclusion

Additional studies are necessary to pinpoint further the determinants and mediators of this relationship. Considering the high prevalence rate of depression in this community and its disabling effects on QOL, interventions to prevent and treat depression are essential. More efforts are needed in clinical settings to train health care practitioners to identify depressed elders with visual impairment and provide appropriate treatment.

Use of prescribed optical devices in age-related macular degeneration

PURPOSE

To evaluate prescribed optical device use in terms of frequency and perceived usefulness among people with age-related macular degeneration (AMD). We also sought to determine the tasks for which they were using their prescribed low vision device(s).

METHODS

One hundred ninety-nine patients with AMD presenting for the first time to the low vision service were recruited from a university-based clinic. Prior to the low vision evaluation and device prescription, they completed the National Eye Institute Visual Function Questionnaire 25, Center for Epidemiological Studies Depression Scale, Short Portable Mental Status Questionnaire, and a general health questionnaire. The low vision evaluation included best-corrected Early Treatment of Diabetic Retinopathy Study visual acuity, MNREAD testing, microperimetry, prescription, and dispensing of optical low vision devices. Telephone follow-up interviews were conducted about device usage 1-week, 1-month, and 3-months postintervention.

RESULTS

One hundred eighty-one participants were prescribed low vision devices. Of them, 93% completed all 3 follow-up interviews. Intensive users (≥1 hours/day) of devices were similar in demographic and visual characteristics to non-intensive users (<1 hours/day), except for habitual reading acuity and speed as well as contrast sensitivity. Overall, device use increased slightly over 3 months of follow-up. Magnifiers were reported to be moderately-to-extremely useful by >80% of participants at all time points except the 1-month follow-up for hand magnifiers (75%). High plus spectacles were the least frequently prescribed device and rated as moderately-to-extremely useful by 70%, 74%, and 59% at 1 week, 1 month, and 3 months, respectively. Most participants used their devices for leisure reading, followed by managing bills. Very few devices (n = 3, <1%) were not used at any time point.

CONCLUSIONS

Patients with AMD who are provided with prescribed optical low vision devices do use them and perceive them as useful, especially for leisure reading activities. High rates of usage were maintained over 3 month.

Baseline traits of low vision patients served by private outpatient clinical centers in the United States

OBJECTIVE

To characterize the traits of low vision patients who seek outpatient low vision rehabilitation (LVR) services in the United States.

METHODS

In a prospective observational study, we enrolled 764 new low vision patients seeking outpatient LVR services from 28 clinical centers in the United States. Before their initial appointment, multiple questionnaires assessing daily living and vision, physical, psychological, and cognitive health states were administered by telephone. Baseline clinical visual impairment measures and disorder diagnoses were recorded.

RESULTS

Patients had a median age of 77 years, were primarily female (66%), and had macular disease (55%), most of which was nonneovascular age-related macular degeneration. More than one-third of the patients (37%) had mild vision impairment with habitual visual acuity (VA) of 20/60 or greater. The VA correlated well with contrast sensitivity (r = -0.52) but poorly with self-reported vision quality. The intake survey revealed self-reported physical health limitations, including decreased endurance (68%) and mobility problems (52%). Many patients reported increased levels of frustration (42%) and depressed mood (22%); memory and cognitive impairment (11%) were less frequently endorsed. Patients relied on others for daily living support (87%), but many (31%) still drove.

CONCLUSIONS

Most patients seeking LVR are geriatric and have macular disease with relatively preserved VA. The disparity between VA and subjective quality of vision suggests that LVR referrals are based on symptoms rather than on VA alone. Patients seen for LVR services have significant physical, psychological, and cognitive disorders that can amplify vision disabilities and decrease rehabilitation potential.