The impact of diabetic retinopathy on quality of life: qualitative findings from an item bank development project

Understanding data visualization techniques in qualitative studies used to develop and validate patient-reported outcome measures: a targeted literature review

PURPOSE

Qualitative data that reflects patients' experiences are the foundation of any patient-reported outcome measure (PROM) development and validation study; however, there is limited understanding of the type of data visualization techniques that facilitate communication of this data. The goal of this targeted literature review was to investigate data visualization methods that have been used in published PROM development and validation literature to report qualitative results.

METHODS

A literature search in OVID via MEDLINE was conducted among the top 10 non-disease-specific journals publishing PROM qualitative development and validation studies. Studies that reported qualitative methods to develop/validate a PROM and included data visualization in the form of tables or figures were included. Article characteristics and data visualization types were extracted.

RESULTS

A total of 185 articles were included in data extraction. Most articles (n = 109, 59.1%) included figures (n = 172, average 2 relevant figures per article) in the form of hierarchy/flowcharts (n = 124, 72.1%) and bar charts (n = 29, 16.9%). Information reported in figures included depiction of conceptual frameworks (n = 112, 65.1%) and concept frequency (n = 40, 24.4%). Most articles (n = 152, 81.7%) included tables (n = 307, average 2 relevant tables per article). Information reported in tables included concept frequency (n = 133, 43.3%) and cognitive debriefing and revisions (n = 91, 29.6%).

CONCLUSION

Data visualization techniques used to report qualitative results in the identified PROM qualitative development and validation studies were heterogeneous, and many studies did not utilize any data visualization techniques. This study will inform the development of guidance for using data visualizations to report qualitative PROM research.

Global certification of visual impairment registries: A scoping review

BACKGROUND

Visual impairment is a global problem which is predicted to rise in the coming years. Some of the biggest causes of visual impairment globally include uncorrected refractive error, cataract and age-related macular degeneration. People with a visual impairment often require support and so many countries hold registers of visual impairment. These registers can sit at a national, regional or local level. This scoping review aims to identify which countries hold visual impairment registries and have published data from them.

METHODS

Medline All, Embase and EBSCOHost were searched using several search terms after consulting an information specialist. All papers after the year 2000 were included in the scoping review. All results are shown using a PRISMA diagram and presented narratively.

RESULTS

The total number of articles and papers identified was 1266; after screening and review, 57 articles were included in the review from 2000 to 2024. These articles came from 19 different countries and encompassed national, regional and local visual impairment databases. Many countries cited age-related macular degeneration as the major cause of blindness with diabetic retinopathy and glaucoma following. In less economically developed countries, refractive error was the main cause of sight loss. There were papers which focused on specific eye conditions such as glaucoma and diabetic retinopathy or on specific cohorts including working-age population and children. The leading causes of blindness in children appeared to be inherited retinal diseases, albinism and cerebral visual impairment.

CONCLUSION

Certification of visual impairment is held differently across the world. There is commonality among different countries regarding the major causes of visual impairment in both adults and children. The importance of holding visual impairment registers to support people with a visual impairment and to plan services is essential.

Assessment of patient-reported outcomes in vitreomacular interface disorders: A systematic literature review

Patient-reported outcome measures (PROMs) assess the impact of disease on quality of life from the patient's perspective. Our purpose was to provide an overview of current PROMs used for vitreomacular interface disorders: macular hole, epiretinal membrane, and vitreomacular traction. We review the content coverage of all identified PROMs, assess them against quality-of-life issues as identified from earlier qualitative studies, and assess their psychometric quality (measurement properties). We identified 86 studies that used a PROM and 2 qualitative studies on quality of life of patients with a vitreomacular interface disorder. Current PROMs used in vitreomacular interface disorders have a limited content coverage and unknown psychometric quality. The National Eye Institute Visual Functioning Questionnaire was used most. None of the condition-specific PROMs used patient consultation during content development, and there is only a small overlap between the content of PROMs and quality-of-life issues in qualitative studies. Reporting of psychometric quality was sparse and mostly limited to concurrent validity and responsiveness. There is a need for properly developed and validated PROMs in vitreomacular interface disorders.

What do adults with visual impairment mean by well-being? Identifying the building blocks of well-being in the context of visual impairment

Background

Well-being has become a key outcome of health and support services for adults with visual impairment (V.I.). However, there is a lack of consensus on how well-being is conceptualized and assessed in V.I. research, if it is defined at all. A shared understanding of what well-being means in the context of adult V.I. is essential to enable comparison of findings across studies and collaboration between support organizations.

Methods

This article reports findings from a series of four online focus groups with adults with V.I. and one with practitioners working in the field of adult V.I. The focus groups explored what participants meant by well-being and which factors impacted their well-being. A total of 17 adults with V.I. and five practitioners took part. A list of all components of well-being, factors that impact well-being, and items in the protective buffer that may mitigate the impact of factors on well-being were extracted from the data.

Results

Despite the noted difficulty in defining well-being and disagreement around the extent to which well-being was universal or individual, a preliminary model of well-being emerged from the focus group discussions. The core of well-being reflects an overall feeling of contentment arising from a positive evaluation of how one is feeling, how one is feeling within oneself, and how one is feeling about one's life. Factors relating to balance/equilibrium, health, mood, other people, the self, and a sense of security and purpose can positively or negatively impact well-being. This impact may be mitigated by a protective buffer consisting of one's mood, mindset, ability to cope, resilience, and acceptance. Many items were discussed in multiple roles, e.g., as a component of well-being or factor.

Conclusion

This research took a bottom-up approach to explore what well-being means in the context of adult V.I. The role of certain items and the structure of the proposed model of well-being will need to be confirmed in future research with stakeholders across the V.I. sector.

The NaviSight Study: Investigating How Diabetic Retinopathy and Retinitis Pigmentosa Affect Navigating the Built Environment

Background: Visual impairment is a global problem and, regardless of the cause, it substantially impacts people’s daily lives. Navigating towns and cities can be one of the most difficult tasks for someone with a visual impairment. This is because our streetscapes are often inaccessible for navigating safely and independently by people with a visual impairment. Barriers include street clutter, bollards, pavement parking, and shared spaces. Methodology: Participants with varying levels of diabetic retinopathy (DR) and retinitis pigmentosa (RP) were recruited. Each participant completed a clinical visit and a 1-mile walk. Participants discussed confidence, anxiety, difficulty, and any barriers encountered while completing the walkaround. Participants completed quality of life (RetDQol), diabetes distress scales, and a study questionnaire. They also underwent retinal imaging and visual function testing. Retinal imaging and visual function results were compared with confidence, difficulty, and anxiety levels during the walkaround using Spearman’s correlation. Results: Thirty-three participants took part in the study, 22 with diabetes and 11 with RP. Results showed that average confidence was correlated with visual acuity, RetDQol, mean visual fields, and vertical peripheral diameter visual fields. Average difficulty was associated with visual acuity, RetDQol, dark adaptation, mean visual fields, percentage of the retina, and both horizontal and vertical diameter visual fields. In addition, some of the barriers discussed were pavement issues, bollards, parked cars, uneven pavements, alfresco dining, light levels, and street features such as tree roots, poles, A-boards, and street clutter. Conclusions: People with RP and treated DR faced common barriers while navigating the walkaround. The removal of these common barriers would make our streetscapes more accessible for all and will allow for more independence in those with visual impairments.

Vision-Related Quality of Life Among Diabetic Retinopathy Patients in a Hospital-Based Population in the Sultanate of Oman

Background

The global prevalence of diabetic retinopathy (DR) among individuals with diabetes is 22.27%. This highlights the likelihood of developing burden of retinopathy within the at risk population and can have a detrimental impact on an individual's quality of life (QoL). The aim of this study is to assess the vision-related QoL in individuals with (DR) in a hospital-based population in the Al-Buraimi governorate, Sultanate of Oman.

Methods

The study was conducted in the Ophthalmology Outpatient Department of Al Buraimi Hospital and Polyclinic. This study enrolled 218 patients (114 males, 104 females) diagnosed with DR. The NEI-VFQ-25 questionnaire was adopted in this study. The patients were classified into different groups according to their type of diabetes and other relevant demographic information.

Results

A total of 218 patients responded to the NEI-VFQ-25 questionnaire. The mean age of the participants was 57.49 ± 12.3 years, 52.3% were male, and 47.7% were female. The overall QoL score was 41.53± 20.8. Patients aged more than 75 years had the lowest QoL scores compared with the other age groups (p = 0.02). The results showed that the duration of diabetes had no significant impact on the overall QoL scores (p = 0.06). A higher QoL score was observed among patients with type II diabetes mellitus (DM) than with type I diabetes mellitus (p = 0.01). Patients diagnosed with proliferative DR (PDR) had a significantly lower QoL score than those diagnosed at other stages (p < 0.001).

Conclusion

The QoL of the population with DR is negatively affected by various factors, including demographics, disease severity, and in patients with DM type II. It is important to consider these factors to enhance QoL in patients with DR. Regular evaluation of an individual's QoL is beneficial for both physicians and healthcare teams.

How does the UK public think and feel about people with visual impairment: a review of existing evidence

Despite legislation to protect people with visual impairment (V.I.) from discrimination in the United Kingdom (UK), the latter continue to experience overt and covert negative behaviours. Perceived discrimination has been associated with an adverse impact on identity, health and well-being, while negative attitudes have been identified as the biggest barrier to participation in everyday life. This article provides a narrative review of existing evidence of how the UK public treats (behaviours), thinks (perceptions) and feels (attitudes) about people with V.I. Despite limitations, the findings suggest that there is a gap between the behaviours reported by people with V.I. and the attitudes expressed by members of the UK public. Social psychological theories are used to explore possible reasons for this gap, and ways in which it may be addressed. As such, the article provides an example of how social psychological theories can be used to address problems in an applied context.

Measuring Quality of Life in Diabetic Retinal Disease: A Narrative Review of Available Patient-Reported Outcome Measures

Topic

Several patient-reported outcome measures (PROMs) are available to measure health-related quality of life (HRQoL) in patients with late-stage clinical diabetic retinal diseases (DRDs). However, an understanding of the psychometric properties of PROMs is needed to assess how they could relate to severity levels of a revised DRD grading system. This narrative review assessed the available generic-, vision-, and DRD-related PROMs used in DRD research and highlights areas for improvement.

Clinical Relevance

Diabetic retinal disease is a common complication of diabetes and can lead to sight-threatening complications with a devastating effect on HRQoL.

Methods

The Quality of Life working group is one of 6 working groups organized for the DRD Staging System Update Effort, a project of the Juvenile Diabetes Research Foundation Mary Tyler Moore Vision Initiative. PubMed, Cochrane Library, Embase, and Google Scholar databases were searched using core keywords to retrieve ophthalmology-related review articles, randomized clinical trials, and prospective, observational, and cross-sectional studies in the English language. A detailed review of 12 PROMs (4 QoL questionnaires and 8 utilities) that met a minimum level of evidence (LOE) was conducted. The relevance of each PROM to DRD disease stage and Biomarker Qualification guidelines (Biomarkers, EndpointS, and other Tools) categories was also defined.

Results

The National Eye Institute 25-item Visual Function Questionnaire (NEI VFQ-25), Impact of vision impairment-computerized adaptive testing, and Diabetic Retinopathy and Macular Edema Computerized Adaptive Testing System had a LOE of II in detecting change due to late-stage DRD (diabetic macular edema), although several areas for improvement (e.g., psychometrics and generalizability) were identified. Other PROMs, particularly the utilities, had a LOE of III due to cross-sectional evidence in late-stage clinical DRD. Although the NEI VFQ-25 has been the most widely used PROM in late-stage DRD, more work is required to improve its multidimensional structure and other psychometric limitations. No PROM was deemed relevant for subclinical or early/mid-DRD.

Conclusion

This narrative review found that the most commonly used PROM is NEI VFQ-25, but none meets the ideal psychometric, responsiveness, and clinical setting digital administration requirements that could be included in an updated DRD staging system for diagnosis and monitoring of DRD progression.

Financial Disclosures

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

Social functioning in adults with visual impairment from minority ethnic communities in the United Kingdom

Background

Visual impairment (V.I.) has been associated with a negative impact on social functioning, while social support can impact on well-being in those with V.I. Adults from minority ethnic communities (MEC) are projected to make up an increasing proportion of adults living with V.I. in the UK, but limited research has explored their social functioning. This article provides a preliminary insight into social functioning among MEC adults living with V.I. in the UK.

Methods

The article reports findings from a secondary analysis of V.I. Lives survey data. V.I. Lives was a UK telephone survey, which explored the life experiences of people with V.I. across a wide range of topics including social functioning. This secondary analysis explored social participation, support, isolation, and relationships among a matched control sample of 77 MEC and 77 adults aged 18 and over from White communities (WC). Participants were matched on age, gender, UK region and urban/rural setting. Subgroup analyses were also conducted for the two largest subgroups within the MEC group, Asian (n = 46) and Black participants (n = 22).

Results

Contact with like-minded people (U = 2174.50, p = 0.003, r = -0.24) and opportunities to take part in more social activities (U = 2253.50, p = 0.007, r = -0.22) was significantly more important to MEC than WC participants. Moreover, MEC participants were significantly less likely to feel supported by friends/family (U = 3522.50, p = 0.017, r = 0.19) and had fewer people they could ask for help (U = 3775.50, p = 0.001, r = 0.26), but there were no significant differences in the perceived impact of V.I. on their friendships/social life and marriage/relationship, their ability to take part in a range of activities, nor their marital status. Asian participants were significantly more likely than Black participants to feel cut off from the people and places around them (U = 655.50, p = 0.042, r = 0.25). Effect sizes were overall small. Although there were no further statistically significant differences between the two groups, Asian participants were also less likely to be able to take part in activities, and more likely to report a negative impact on their social life/friendships and on their marriage/relationship, as well as a smaller social network.

Conclusion

The findings suggest that V.I. may have had a greater impact on social functioning among Asian participants in this sample, including on experiences of social isolation and participation in social activities. Future research will need to confirm these findings and explore the possible reasons.

Access to eye care and support services among adults from minority ethnic communities living with visual impairment in the United Kingdom

Background

Despite an increased risk of certain eye conditions which can lead to visual impairment (V.I.), there is evidence of a greater delay to treatment-seeking among adults from minority ethnic communities (MEC). MEC adults may also be underrepresented on V.I. registers, within early intervention services, and among the beneficiaries of national V.I. charities. However, much of this evidence is outdated or anecdotal.

Methods

This secondary analysis of V.I. Lives survey data explored use of eye health and support services and mobility aids among a matched control sample of 77 MEC and 77 adults aged 18 and over from white communities (WC). Participants were matched on age, gender, UK region and urban/rural setting. Additional subgroup analysis was conducted for Asian (n = 46) and black participants (n = 22).

Results

There were no significant group differences in areas such as eye health service use, registration status, contact with charities, and level of practical support received. But MEC participants were significantly more likely than WC participants to have received direct payments from social services to cover their care needs, Χ2 (1, 154) = 8.27, p = 0.004, and to use apps on their mobile for mobility, Χ2 (1, 154) = 5.75, p = 0.017. In contrast, WC participants were significantly more likely to agree that they were getting the level of emotional support to get on with their life, U = 3,638, p = 0.010, to feel confident to ask their friends for support, U = 2,416, p = 0.040, and to have a guide dog for mobility, Χ2 (1, 154) = 3.62, p = 0.057, although the latter did not reach statistical significance. Within the MEC group, Asian participants were significantly more likely than black participants to use a long cane, Χ2 (1, 68) = 7.24, p = 0.007, but they were significantly less likely to agree that they had received the right level of support when they started to experience V.I., U = 236.5, p = 0.040.

Conclusion

The preliminary findings suggests that there is scope to increase support provided by V.I. charities and the V.I. register, although, contrary to existing evidence, there were no statistically significant differences in eye health service use, registration status and use of wider support services. Further research is required to confirm these findings and explore reasons for differences.

Exploring mental well-being, the emotional impact of visual impairment and experiences of prejudice and discrimination among adults from minority ethnic communities in the UK

Background

Visual impairment (V.I.) has been associated with a negative impact on mental health outcomes, including a process of grief among those who lose their sight. Older adults with V.I. who had experienced discrimination have been found to be at increased risk of depression, loneliness, poorer life satisfaction and poorer quality of life. Adults from minority ethnic communities (MEC) may be at increased risk of V.I. and yet, research on the experiences of MEC adults with V.I. remains limited. This article forms part of a series which explores issues and status among MEC adults living with V.I. in the UK.

Methods

A secondary analysis of V.I. Lives survey data was performed to explore mental well-being assessed by the short Warwick-Edinburgh Mental Well-being scale (SWEMWBS), the emotional impact of V.I., and prejudice and discrimination among a matched control sample of 77 MEC and 77 adults from white communities (WC). Participants were matched by age, gender, UK region and urban/rural setting. Subgroup analyses were also conducted for the two largest MEC subgroups, Asian (n = 46) and black participants (n = 22).

Results

There were few statistically significant differences between the groups. MEC participants were significantly more likely than WC participants to rate emotional support to come to terms with their V.I. as important and to feel optimistic about their V.I. but they were significantly less likely to agree that they were receiving the level of emotional support they needed to get on with their life. Within the MEC group, participants from Asian communities had significantly poorer mental well-being, and they were also significantly more likely to agree that the general public were often prejudiced against people with V.I. and less likely to feel optimistic about their V.I. than black participants.

Conclusion

Although there were few statistically significant differences, participants from Asian communities were more likely to report poor mental and emotional well-being, and experiences of discrimination, than black and white participants. In contrast, participants from black communities fared the same as, or in some cases better than, white participants. Future research will need to confirm these findings and explore reasons for these.

Patient-reported outcomes in patients with vitreous floaters: A systematic literature review

Seeking treatment for bothersome vitreous floaters is patient driven. To measure the impact of floaters and treatment on an individual's quality of life, patient-reported outcome measurements (PROMs) are essential. We review all studies using a PROM for patients with floaters. We evaluated content coverage against quality-of-life domains previously identified in other ophthalmic disorders, and against a qualitative study investigating quality-of-life issues in patients with floaters. We assessed measurement properties of PROMs using an extensive range of psychometric quality criteria. We identified 59 studies using 28 different PROMs. Many PROMs were not specifically developed for patients with floaters. Floater-specific PROMs were mostly based on content validation from an ophthalmologist or researcher perspective; two included a patient perspective. Using the outcomes of the qualitative study, we found that the floater-specific PROMs were narrow in their content coverage, with most items relating to visual symptoms and activity limitations. Testing the psychometric quality of PROMs was rare, and when employed mostly limited to responsiveness and known group validity. The remarkable high number of floater-specific PROMs reveals a need for such measurements in ophthalmology. Unfortunately, reporting on psychometric quality is limited, and content development is most often done without patient involvement.

Diabetic Retinopathy Screening at the Point of Care (DR SPOC): detecting undiagnosed and vision-threatening retinopathy by integrating portable technologies within existing services

INTRODUCTION

The aim of this study was to determine the prevalence of diabetic retinopathy (DR) in a low socioeconomic region of a high-income country, as well as determine the diagnostic utility of point-of-care screening for high-risk populations in tertiary care settings.

RESEARCH DESIGN AND METHODS

This was a cross-sectional study of patients with diabetes attending foot ulcer or integrated care diabetes clinics at two Western Sydney hospitals (n=273). DR was assessed using portable, two-field, non-mydriatic fundus photography and combined electroretinogram/ pupillometry (ERG). With mydriatic photographs used as the reference standard, sensitivity and specificity of the devices were determined. Prevalence of DR and vision-threatening diabetic retinopathy (VTDR) were reported, with multivariate logistic regression used to identify predictors of DR.

RESULTS

Among 273 patients, 39.6% had any DR, while 15.8% had VTDR, of whom 59.3% and 62.8% were previously undiagnosed, respectively. Non-mydriatic photography demonstrated 20.2% sensitivity and 99.5% specificity for any DR, with a 56.7% screening failure rate. Meanwhile, mydriatic photography produced high-quality images with a 7.6% failure rate. ERG demonstrated 72.5% sensitivity and 70.1% specificity, with a 15.0% failure rate. The RETeval ERG was noted to have an optimal DR cut-off score at 22. Multivariate logistic regression identified an eGFR of ≤29 mL/min/1.73 m2, HbA1c of ≥7.0%, pupil size of <4 mm diameter, diabetes duration of 5-24 years and RETeval score of ≥22 as strong predictors of DR.

CONCLUSION

There is a high prevalence of vision-threatening and undiagnosed DR among patients attending high-risk tertiary clinics in Western Sydney. Point-of-care DR screening using portable, mydriatic photography demonstrates potential as a model of care which is easily accessible, targeted for high-risk populations and substantially enhances DR detection.

Comparative Analysis of Health- and Vision-Related Quality of Life Measures among Trinidadians with Low Vision and Normal Vision-A Cross-Sectional Matched Sample Study

This cross-sectional study investigated the health-related and vision-related quality of life measures of adults with low vision compared to healthy individuals in Trinidad and Tobago. The health-related quality of life (HRQOL-14) and the National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) were administered to 20 participants with low vision caused by diabetic retinopathy, retinitis pigmentosa, glaucoma, and macular degeneration, as well as 20 participants with no visual problems (control). Participants were recruited from the University Eye Clinic in Trinidad and Tobago. Compared to the controls, more participants in the low-vision group had lower age-adjusted NEI-VFQ-25 scores (48.3% vs. 95.1%; p < 0.001), had poor general (47.5% vs. 10%, p = 0.004) and mental (100% vs. 10%, p < 0.042) health, experienced greater activity limitation due to impairment or health problems (85% vs. 20%, p < 0.001), needed help with personal care (27.5% vs. 0%, p < 0.009) and daily routine (67.5% vs. 0%, p < 0.001), and experienced sleep problems (97.5% vs. 65%, p < 0.001) and symptoms of anxiety (100% vs. 90%, p = 0.042). All the diabetic retinopathy participants (100%, p = 0.028) had two or more impairments or vision problems compared to none in the other low-vision participants. In summary, the HRQOL-14 and NEI-VFQ-25 scores were significantly reduced in low-vision participants, who also demonstrated a greater vulnerability to poor quality of life in the presence of diabetes retinopathy. These findings have important clinical implications regarding offering appropriate support and interventions to improve quality of life outcomes in individuals with low vision.

Association between sight-threatening eye diseases and death by suicide in South Korea: a nationwide population-based cohort study

PURPOSE

Although associations between visual impairment (VI) and suicide are posited, specific risks across the sight-threatening eye disease (STED) spectrum remain to be assessed. We determined whether individuals with STED die more often by suicide than do other people and assessed the temporal associations.

DESIGN

A nationwide, population-based cohort study.

PARTICIPANTS

All persons aged 40 years or older in South Korea from 2010 to 2020.

METHODS

Persons diagnosed with STEDs (i.e., glaucoma, exudative age-related macular degeneration [AMD], or diabetic retinopathy [DR]) were identified in the Korean National Health Insurance (NHI) service database. Both NHI health checkup records and the National Disability Registration were used for coexisting severe VI. Death by suicide was defined as diagnostic codes as recorded in the Korea National Statistical Office. Incidence rate ratios (IRRs) were estimated by quasi-Poisson regressions and adjusted for sociodemographics, comorbidity, psychiatric diagnoses, and VI. The temporal relationship between time since first STED diagnosis and suicide risk was determined by identifying patients with STED newly diagnosed during the period from 2010 to 2011.

MAIN OUTCOME MEASURES

The IRR of death by suicide in people with STED relative to those without.

RESULTS

Of the 2.8 million people (45% male) observed for 24 300 969 person-years, 13 205 died by suicide. Among them, 34% (n = 4514) had a STED diagnosis, for a suicide rate of 69 per 100 000 person-years (95% confidence interval [CI], 67-72), relative to 51 per 100 000 person-years (95% CI, 50-52) for non-STED individuals. People with STED had an adjusted IRR of 1.33 (95% CI, 1.26-1.41) relative to those without. The largest excess adjusted IRR of suicide mortality was that for DR (1.40, 95% CI, 1.29-1.52). For exudative AMD, the adjusted IRR was 1.20 (95% CI, 1.04-1.39), whereas for glaucoma, the corresponding value was 1.09 (95% CI, 1.02-1.17). With coexisting severe VI, the IRR for any STED was 1.49 (95% CI, 1.29-1.73). The highest suicide hazard ratio was between 3 and 6 months postdiagnosis (5.33; 95% CI, 4.59-6.20).

CONCLUSIONS

In South Korea between 2010 and 2020, a higher suicide rate was evident among those with diagnosed STED than for persons not so diagnosed.

FINANCIAL DISCLOSURE(S)

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

A rapid review of evidence relating to service use, experiences, and support needs of adults from minority ethnic communities along the eyecare pathway in the United Kingdom

Background

There is growing awareness of the health inequalities experienced by minority ethnic communities, who make up an increasing proportion of the United Kingdom (UK) population and have been found to be at increased risk of visual impairment (V.I.). V.I. impacts on a wide range of life domains including employment, social functioning and activities of daily living. Considering existing health inequalities, the increased risk of V.I. and its wide-ranging impact, it is important to understand the experiences of adults from minority ethnic communities living with V.I. in the UK.

Methods

A rapid evidence review of academic and gray literature published since 2005 and in English was performed. A search of AMED, CINAHL Plus and MEDLINE via EBSCOhost identified 969 articles. Articles were included in the review if they reported findings relating to the UK-context, to adults from minority ethnic communities living with V.I., and to experiences of V.I. and the eyecare pathway.

Results

A total of 11 academic articles and 4 charity reports presented findings relating to perceptions of V.I. and eye disease (n = 3), access to services and service use (n = 5), impact of interventions (n = 7), the wider impact of V.I. (n = 2), and registration status (n = 1). Much of the literature focused on primary eyecare resulting in a comprehensive list of barriers and recommendations to increase eye tests. Less research addressed experiences and use of services further along the eyecare pathway although use of services may be low. Overall, the research on the experiences of adults with V.I. from minority ethnic communities in the UK remains anecdotal, outdated or unavailable. There are substantial gaps in the evidence relating to the wider impact of V.I., the impact of perceptions of V.I., and the use of services beyond primary eyecare.

Conclusions

This review summarizes our current knowledge of the experiences of adults from minority ethnic communities living with V.I. in the UK and highlights substantial gaps in the evidence. The findings provide practical implications for practitioners and researchers committed to addressing health inequalities in the field of eyecare in the UK.

Conceptualizations of well-being in adults with visual impairment: A scoping review

Background

Despite its ubiquity, it is often not clear what organizations and services mean by well-being. Visual impairment (VI) has been associated with poorer well-being and well-being has become a key outcome for support and services for adults living with VI. A shared understanding of what well-being means is therefore essential to enable assessment of well-being and cross-service provision of well-being support.

Objectives

To provide an overview of the ways in which well-being has been conceptualized in research relating to adults living with VI.

Eligibility criteria

Articles were included in the review if the article discussed well-being in the context of adults living with VI, was available in English and as a full text.

Data sources

A systematic search using search terms relating to VI and well-being was conducted in EBSCOHost (Medline, CINHL) and Ovid (Embase Classic, Embase, Emcare 1995, Health + Psychosocial, HMIC Health Management Info, APA, PsycArticles, PsycInfo, PsycTests).

Charting

A team of three reviewers screened titles, abstracts and full-texts articles and extracted data. Ambiguous articles were referred to the research group and discussed.

Results

Of 10,662 articles identified in the search, 249 were included in the review. These referred to 38 types of well-being. The most common types were general well-being (n = 101; 40.6%) emotional well-being (n = 86, 34.5%) and psychological well-being (n = 66, 26.5%). Most articles (n = 150; 60.2%) referred to one type only, with a maximum of 9 listed in one article. A large number of articles did not clearly define well-being. A wide range of indicators of well-being related to the domains of hedonia, mood, positive and negative affect, quality of life, mental health, eudaimonia, self/identity, health, psychological reactions to disability and health problems, functioning, social functioning and environment, were extracted, many of which were used just once.

Conclusions

There remains a lack of consensus on how well-being is conceptualized and assessed in the context of adult VI. A standardized multi-domain approach derived with input from adults with VI and practitioners working with them is required to enable comparison of findings and cross-organizational provision of support.

Living Without a Diagnosis: A Patient's Perspective on Diabetic Macular Ischemia

Diabetic macular ischemia (DMI) is a common complication of diabetic retinopathy (DR) that can result in progressive and irreversible vision loss. DMI is associated with damage in the vessels that supply blood to the retina and the enlargement of the foveal avascular zone. Currently, there are no approved treatments specifically for DMI. Furthermore, there is limited published information about the prognosis, prevalence or outcomes of DMI, and there is no consensus regarding diagnostic criteria. It is vital to ensure that there is sufficient, accessible and accurate information available to support patients, caregivers and physicians. To lay the foundation for more research into DMI and its impact on patients, we (a patient with DMI and an expert ophthalmologist) have worked together to interweave our personal perspectives and clinical experiences with a review of currently available literature on DMI. The development of a set of confirmed diagnostic criteria for DMI would assist both patients and physicians, allowing patients to access validated information about their condition and supporting the development of clinical trials for treatments of DMI. Training for physicians must continue to emphasise the importance of treating a patient holistically, rather than only treating their symptoms. Most importantly, developing trust and a healthy rapport between a patient and their physician is important in managing health anxiety and ensuring adherence to beneficial treatments or lifestyle adjustments; physicians must cultivate an open and flexible management approach with their patients. Finally, holistic educational programmes for patients, physicians and the general public around DMI and how it can affect daily functioning would facilitate general understanding and disease awareness.

Diabetic macular ischemia (DMI) is a common problem for patients with diabetic retinopathy that can lead to sight loss. There is very little information available about DMI, particularly from a patient’s point of view. To address the lack of information about DMI, we (a person with DMI and her eye doctor) have worked together to examine what it is like to live with DMI. It is important to provide clear and accessible information about diseases to patients and carers. The lack of information about DMI may be upsetting for some people, and should be addressed with more research. Developing of a set of confirmed signs and symptoms for the diagnosis of DMI would allow people to be more confident in the information that they receive about their disease, and support the development of treatments for DMI. The support of others is central to the wellbeing of people with vision loss. Although people with vision loss may also lose independence, care from loved ones can help to improve quality of life. Most importantly, developing trust between a patient and their doctor is central to managing people’s fears about their eyesight, and making sure that they follow helpful advice. Doctors must use an open and flexible approach with their patients, providing information in an honest and understandable way.

Capturing the experiences of patients with inherited optic neuropathies: a systematic review of patient-reported outcome measures (PROMs) and qualitative studies

PURPOSE

To identify and comprehensively evaluate studies capturing the experience of individuals affected by an inherited optic neuropathy (ION), focusing on patient-reported outcome measures (PROMs) and qualitative studies where the health status and quality of life (QoL) of these individuals have been explored.

METHODS

Systematic review of five databases using a search strategy combining four concepts: (1) ION; (2) QoL and health status; (3) PROMs; and (4) qualitative research. Studies assessing the impact of ION on any QoL domain using a PROM or qualitative methodology were included and appraised, using criteria based on the COSMIN checklist (for PROM studies) and the CASP checklist (for qualitative studies).

RESULTS

Of 1326 unique articles identified, six studies were included. Five PROMs were identified: Visual Function Index (VF-14); Hospital Anxiety and Depression Scale (HADS); a novel graphical online assessment tool (NGOAT) for reporting emotional response to vision loss; a new PROM informed by the DSM-V Criteria for Major Depressive Disorder; and an interpersonal and career 'impact rating' PROM. The psychometric performance of included PROMs were poorly described. Qualitative studies found that vision loss resulted in psychosocial losses including loss of social and communication skills and loss of independence and freedom. Factors that modified the response to vision loss were also identified.

CONCLUSION

The current PROMs used by individuals with ION have poor content coverage, primarily measuring activity limitation and emotional well-being, and insufficient reporting of psychometric performance. There is a need to develop a PROM for individuals ION to report their experiences of living with their condition.

Galectin-1 and -3 in high amounts inhibit angiogenic properties of human retinal microvascular endothelial cells in vitro

Purpose

Galectin-1 and -3 are β-galactoside binding lectins with varying effects on angiogenesis and apoptosis. Since in retinal pigment epithelial cells high amounts of human recombinant galectin (hr-GAL)1 and 3 inhibit cell adhesion, migration and proliferation, we investigated if hr-GAL1 and 3 have homologous effects on human retinal microvascular endothelial cells (HRMEC) in vitro.

Methods

To investigate the effect of galectin-1 and -3 on HRMEC, proliferation, apoptosis and viability were analyzed after incubation with 30, 60 and 120 μg/ml hr-GAL1 or 3 by BrdU-ELISA, histone-DNA complex ELISA, live/dead staining and the WST-1 assay, respectively. Further on, a cell adhesion as well as tube formation assay were performed on galectin-treated HRMEC. Migration was investigated by the scratch migration assay and time-lapse microscopy. In addition, immunohistochemical staining on HRMEC for β-catenin, galectin-1 and -3 were performed and β-catenin expression was investigated by western blot analysis.

Results

Incubation with hr-GAL1 or 3 lead to a decrease in proliferation, migration, adhesion and tube formation of HRMEC compared to the untreated controls. No toxic effects of hr-GAL1 and 3 on HRMEC were detected. Intriguingly, after treatment of HRMEC with hr-GAL1 or 3, an activation of the proangiogenic Wnt/β-catenin signaling pathway was observed. However, incubation of HRMEC with hr-GAL1 or 3 drew intracellular galectin-1 and -3 out of the cells, respectively.

Conclusion

Exogenously added hr-GAL1 or 3 inhibit angiogenic properties of HRMEC in vitro, an effect that might be mediated via a loss of intracellular endogenous galectins.

Evaluation of Quality and Bone Microstructure Alterations in Patients with Type 2 Diabetes: A Narrative Review

Bone fragility is a common complication in subjects with type 2 diabetes mellitus (T2DM). However, traditional techniques for the evaluation of bone fragility, such as dual-energy X-ray absorptiometry (DXA), do not perform well in this population. Moreover, the Fracture Risk Assessment Tool (FRAX) usually underestimates fracture risk in T2DM. Importantly, novel technologies for the assessment of one microarchitecture in patients with T2DM, such as the trabecular bone score (TBS), high-resolution peripheral quantitative computed tomography (HR-pQCT), and microindentation, are emerging. Furthermore, different serum and urine bone biomarkers may also be useful for the evaluation of bone quality in T2DM. Hence, in this article, we summarize the limitations of conventional tools for the evaluation of bone fragility and review the current evidence on novel approaches for the assessment of quality and bone microstructure alterations in patients with T2DM.

Exploring the Quality of Life Related to Health and Vision in a Group of Patients with Diabetic Retinopathy

(1) Background: Visual impairment of people with diabetic retinopathy (DR) and its high impact on different dimensions of their lives can cause a significant deterioration in the quality of life. The aim of this study was to examine the association and relationship between quality of life related to vision and the relevant clinical and sociodemographic variables in a group of patients with DR in Spain. (2) Methods: A descriptive cross-sectional study was conducted in all patients with DR over 18 years under follow-up in the Retina Service of the University Hospital of Burgos (HUBU), recruited during the months of January and February 2020. The main study variable was quality of life related to health and vision, obtained using the National Eye Institute Visual Function Questionnaire 25 (NEI-VFQ-25). (3) Results: In total 87 participants made up the sample, and significant differences were found in the NEI-VFQ-25 according to gender, type of diabetes, episodes of decompensated diabetes and high blood pressure (HBP) (p < 0.05). Best-corrected visual acuity (BCVA) was also correlated with the NEI-VFQ-25 (p < 0.05). (4) Conclusions: These data could facilitate the design of action protocols focused on the well-being of the patient, in addition to considering the clinical characteristics. Further studies are needed to help understand the causal relationship between variables and that includes a wider variety of factors.

Factors Associated with Diabetes-Related Distress in Type 2 Diabetes Mellitus Patients

BACKGROUND

Diabetes-related distress is a unique emotional problem that is directly related to the burden and anxieties felt by type 2 diabetes mellitus (T2DM) patients. Diabetes-related distress may lead to pessimism and lower self-efficacy which resulted in a deficiency of self-treatment compliance and can cause further bad glycemic control. Knowing the associated factors of diabetic-related distress and solving them may help T2DM patients improve their glycemic control.

METHODS

This study is an analytical study with cross-sectional design conducted at Sanglah General Hospital from January to April 2021. The data were taken using the consecutive sampling method; 124 samples were collected according to inclusion and exclusion criteria. The participants filled Diabetes Distress Scale questionnaire (DDS17 Bahasa Indonesia). The data analysis was done using univariate (descriptive), bivariate (chi-square) and multivariate (logistic regression) analysis.

RESULTS

Seventy-five subjects out of 124 (60.5%) had diabetes-related distress. The associated factors of diabetes-related distress one among others are the insulin usage as diabetic therapy (OR= 8.30, 95% CI 2.24-30.72; p = 0.002), had a hypoglycaemia in last 3 months (OR=44.59, 95% CI 4.36-455.51; p = 0.001), had diabetes-related retinopathy (OR=10.28, CI 95% 1.54-68.70; p=0.016), and lack of family support (OR=44.791, 95% CI 10.02-200.22; p < 0.001).

CONCLUSION

Our present study revealed that diabetes distress prevalence is predominantly and associated among in type 2 diabetes mellitus. We suggest diabetes-related distress screening and regular health promotion which focus on relationship between diabetes and psychological may be a great potential action to improve public health and patient outcomes.

Knowledge, attitude, and practice patterns and the purported reasons for delayed presentation of patients with sight-threatening diabetic retinopathy at a tertiary eyecare facility in Central India: A questionnaire-based study

Purpose:

To identify the reasons for delayed presentation among patients with sight-threatening diabetic retinopathy (STDR) and to assess their knowledge, attitude, and practice (KAP) patterns in context to diabetes mellitus (DM) and diabetic retinopathy (DR).

Methods:

Single-center, cross-sectional, questionnaire-based KAP survey. All consecutive cases of STDR who presented to our tertiary eye care facility from June 2020 to November 2020 were recruited. The KAP scoring survey tool was incorporated into the questionnaire to help evaluate and represent the patient's disease.

Results:

170 patients with STDR were enrolled in the study. The mean age of patients was 54 ± 9.34 years (Range: 21–70 years); 110 patients (64.7%) were between 41 and 60 years; 131 patients (76%) had DM for more than 5 years. The STDR changes were more prevalent in patients with an educational qualification of high school or less (n = 142; 83.5%). Fifty-two patients (30.6%) had been informed regarding the detrimental effect of diabetes on the eyes and were recommended to consult an ophthalmologist by the treating physician. Of these, 24 (46.15%) patients were educated about retinal changes due to diabetes. Eighty-five (50%) patients in our study had good knowledge about DM; 13 (7.6%) patients had good knowledge about DR. For patients not compliant for follow-ups with the treating physician, the use of “home glucometers for self-monitoring (n = 60, 35.3%) was the most prevalent reason. The main reason for poor compliance for undergoing a dilated fundus examination by the ophthalmologist was “Had good vision, so didn’t feel the need” in 143 (90.5%) patients.

Conclusion:

The absence of visual complaints, lack of knowledge, and failure to undergo a dilated fundus examination in the past were the prevalent risk factors in patients presenting with STDR. Knowledge/practice about DR was poor among the patients with STDR. The treating physicians and ophthalmologists were the most common sources for patient education.

Identifying the content for an item bank and computerized adaptive testing system to measure the impact of age-related macular degeneration on health-related quality of life

PURPOSE

We are developing an age-related macular degeneration (AMD) health-related quality of life (HRQoL) item bank, applicable to Western and Asian populations. We report primarily on content generation and refinement, but also compare the HRQoL issues reported in our study with Western studies and current AMD-HRQoL questionnaires.

METHODS

In this cross-sectional, qualitative study of AMD patients attending the Singapore National Eye Centre (May-December 2019), items/domains were generated from: (1) AMD-specific questionnaires; (2) published articles; (3) focus groups/semi-structured interviews with AMD patients (n = 27); and (4) written feedback from retinal experts. Following thematic analysis, items were systematically refined to a minimally representative set and pre-tested using cognitive interviews with 16 AMD patients.

RESULTS

Of the 27 patients (mean ± standard deviation age 67.9 ± 7.0; 59.2% male), 18 (66.7%), two (7.4%), and seven (25.9%) had no, early-intermediate, and late/advanced AMD (better eye), respectively. Whilst some HRQoL issues, e.g. activity limitation, mobility, lighting, and concerns were similarly reported by Western patients and covered by other questionnaires, others like anxiety about intravitreal injections, work tasks, and financial dependency were novel. Overall, 462 items within seven independent HRQoL domains were identified: Activity limitation, Lighting, Mobility, Emotional, Concerns, AMD management, and Work. Following item refinement, items were reduced to 219, with 31 items undergoing amendment.

CONCLUSION

Our 7-domain, 219-item AMD-specific HRQoL instrument will undergo psychometric testing and calibration for computerized adaptive testing. The future instrument will enable users to precisely, rapidly, and comprehensively quantify the HRQoL impact of AMD and associated treatments, with item coverage relevant across several populations.

Self-Instructional Training Application on Diabetic Patients' Self-Care Behaviors

Background: The diabetes mellitus cases have significantly increased in Indonesia over recent years. Health education for patients has often been carried out; however, education using self-instructional methods, which provided self-learning to solve problems by adjusting the patient's ability to improve self-care behaviors, has not been widely used.Purpose: This study aimed to analyze the self-care behaviors of diabetic patients with the application of self-instructional training.Methods: This research was a quasi-experimental study with a non-equivalent pretest-posttest with a control group design. The participants were 73 diabetic patients in the out-patient units selected by a purposive sampling technique, and divided into two groups: the intervention group (n=37) and the control group (n=36). The intervention group received a self-instructional training program which was carried out in two sessions using a booklet; each session lasted for 45 minutes. The Summary of Diabetes Self-Care Activities (SDSCA) questionnaire was used to collect diabetic patients' self-care behavior data. Wilcoxon and Mann-Whitney tests were employed for data analysis.Results: Self-care behaviors of patients with diabetes mellitus increased before and after the training in both groups (p=0.000). However, the increase in the intervention group was higher than that in the control group, from 46.46±5.014 to 58.03±7.320 and from 47.78±4.929 to 51.64±6.406, respectively. There was also a significant difference in the self-care behaviors of diabetic patients between the intervention group and the control group (p=0.000).Conclusion: Self-instructional training significantly improves self-care behaviors of diabetic patients. Therefore, self-instructional training can be considered to apply in the clinical setting for improving self-care behaviors of diabetic patients to prevent complications, and for enhancing nursing care of diabetes mellitus.

Does non-strabismic amblyopia affect the quality of life of adults? Findings from a qualitative study

PURPOSE

While much is known about the psychosocial impacts of strabismus, little is known about the effects of non-strabismic amblyopia on quality of life (QoL). The aim of this study was to explore the long-term impacts of anisometropic amblyopia.

METHODS

A phenomenological qualitative investigation was carried out on a sample of adults with anisometropic amblyopia. Subjects participated in in-depth telephone interviews and described how their eye condition affected different aspects of their life. The interviews were audio-recorded, transcribed verbatim and analysed iteratively to form emergent themes.

RESULTS

Sixteen participants took part in the study (median age: 21.5 years; range: 18-36 years; 11 male and 5 female). Six themes emerged: (1) symptoms experienced by participants, (2) concerns and apprehensions, (3) emotional impacts, (4) activity limitations, (5) hassle and inconveniences and (6) economic and career implications. Symptoms reported by participants ranged from glare to difficulty concentrating. They were extremely concerned about the safety of their better eye and lived with several doubts and anxieties. Negative emotions such as grief and disappointment due to eye care negligence in childhood was apparent. Guilt and regretful feelings were present in those who did not comply with past treatment. Participants expressed several limitations in driving, reading, mobility (e.g., using stairs) and tasks requiring high resolution. Reported inconveniences associated with coping with their eye condition included having to travel across the country in search of a cure for their amblyopia. Economic impacts ranged from costs associated with accessing eye care and management to career choices being compromised.

CONCLUSION

Lived experiences of people with anisometropic amblyopia indicate that the QoL impacts are multifaceted and substantial, even in the absence of strabismus. The results have the potential to influence patient-practitioner relationship by opening newer horizons to communication and care while managing adult amblyopes.

Assessment of quality of life of the patients with diabetic retinopathy using National Eye Institute Visual Functioning Questionnaire (VFQ-25)

BACKGROUND

Diabetes affects most of the organs causing macrovascular and microvascular complications. Diabetic retinopathy (DR) results from the prolonged uncontrolled hyperglycemia which causes impairment of vision. Quality of life (QoL) of patients with DR is affected due to vision loss. National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) is the questionnaire used to study the effect of DR on QoL.

OBJECTIVES

To assess the QoL of the patients with DR.

MATERIALS AND METHODS

The study enrolled 149 (male-104 and female 45) patients with DR. The previous translated and validated version of NEI-VFQ-25 questionnaire was used in the study.

RESULTS

Cronbach alpha for internal consistency was between 0.6 and 0.8. The male patient showed significantly higher (p<0.05) QoL scores (60.73±1.63) as compared to the female patients (53.15±2.84). Hypertensive patients showed poor QoL as compared to non-hypertensive patients. The patients with a history of diabetes for 16-30 yrs. showed better QoL as compared to other patients.

CONCLUSION

DR affects the QoL of life of patients. Routine assessment of QoL using NEI-VFQ-25 questionnaire would be useful for physicians and health care team.

Sodium-glucose co-transporter 2 inhibitors and diabetic retinopathy: insights into preservation of sight and looking beyond

Sodium-glucose co-transporter 2 Inhibitors (SGLT2i) were initially developed as therapeutic options for patients with type 2 diabetes mellitus (T2DM). Recently, randomized clinical trials have investigated their effects in cardiorenal protection through major adverse cardiovascular event reduction and reductions in diabetic nephropathy. While multiple mechanisms are proposed for this protection, microvascular protection is the primary component of their efficacy. While not primarily emphasized in clinical trials, evidence in other studies suggests that SGLT2i may confer retinoprotective effects via some of the same mechanisms in the aforementioned cardiorenal trials. Diabetic patients are susceptible to vision loss with chronic hyperglycemia promoting inflammation, edema, and retinal pathological changes. Targeting these pathways via SGLT2i may represent opportunities for providers to decrease retinopathy in high-risk T2DM patients, reduce disease progression, and lower drug burden in diabetic retinopathy patients. Further comprehensive clinical trials investigating these associations are needed to establish the potential retinoprotective effects of SGLT2i.

Measures of visual disturbance in patients receiving extended depth-of-focus or trifocal intraocular lenses

The degree of visual disturbance associated with a particular model of intraocular lens (IOL) depends on several factors, including IOL optic, material, and mechanics. Characterization of visual disturbance profiles is paramount for informing clinical IOL selection. Although many studies evaluating presbyopia-correcting IOLs include subjective assessment of visual symptoms, the types of patient-reported outcome measures (PROMs) used to capture these outcomes are inconsistent across studies, complicating data contextualization. Furthermore, some tools produce more meaningful results than others. This review presents a discussion on the scientific literature published on the subjective and semiobjective (halo and glare simulator, light-distortion analyzer, vision monitor, and halometers) methods used to assess visual disturbances in patients implanted with trifocal or extended depth-of-focus IOLs, highlighting their advantages and limitations. It underscores the importance of between-study comparisons and the need for standardized PROMs in clinical IOL research to provide more accurate information for IOL selection.

Vision-related quality of life in adults with severe peripheral vision loss: a qualitative interview study

Background

Existing patient-reported outcome (PRO) measures may not be relevant to the full range of functional and vision-related quality of life (VR-QOL) concerns of individuals with vision impairment due to severe peripheral field loss (PFL). Measurement of VR-QOL in severe PFL is important in order to determine the effectiveness of vision rehabilitation interventions for this population. The purpose of this study was to characterize the impact of severe PFL due to retinitis pigmentosa (RP) and glaucoma on VR-QOL as the initial phase in the development of a novel PRO measure.

Methods

Individuals with severe PFL due to RP or glaucoma were recruited from the Kellogg Eye Center and the Association for the Blind and Visually Impaired. Participants completed semi-structured qualitative interviews, the Impact of Vision Impairment (IVI) questionnaire and the RAND 36-Item Health Survey. Interviews were analyzed by two coders using thematic analysis. A matrix analysis was conducted to compare VR-QOL by cause of severe PFL. Sample size was determined by thematic saturation.

Results

The study included 37 participants (19 RP, 18 glaucoma). Median best-corrected visual acuity for those with RP and glaucoma was 20/40 and 20/27.5, while Pelli-Robson contrast sensitivity was 1.2 log contrast sensitivity (logCS) and 1.1 logCS, respectively. Median domain scores on the IVI (reading, mobility, well-being) ranged from a low of − 0.2 to a high of 0.7 logits in those with RP and from 0.5 to 1.2 logits in those with glaucoma. Qualitative interviews identified six VR-QOL themes relevant across participants with both RP and glaucoma, including activity limitations, driving, emotional well-being, reading, mobility, and social function. VR-QOL concerns were largely consistent among those with severe PFL due to RP and glaucoma. These overarching themes contained content relevant to specific challenges related to severe PFL.

Conclusions

There are commonly occurring VR-QOL concerns among individuals with severe PFL due to RP and glaucoma. The outlined themes will serve as the basis for development of the Low Vision Severely Constricted Peripheral Eyesight (LV-SCOPE) Questionnaire.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-020-00281-y.

The nursing outlook of the self- and family management support programs among Indonesian with diabetes: An umbrella review

BACKGROUND AND AIMS

Diabetes is one of the most critical diseases particularly in developing countries such as Indonesia. Various diabetes approaches have been well conducted to prevent complications. However, little has been discussed in association with the achievement of self- and family management support programs in Indonesia. Thus, the objective of the umbrella review is to evaluate the implementation of the self- and family management support programs among Indonesian with diabetes.

METHOD

To guide this review, the revised self- and family management framework developed by Grey, Schulman-Green, Knafl, and Reynolds (2015) was used. A literature search was conducted via online databases including Cochrane, Scopus, ProQuest, SAGE, EBSCO, and PubMed. The inclusion criteria were diabetes studies related to self- and family management in Indonesia; articles published from 2000 to 2019; quantitative, qualitative, and review studies; used humans as research subjects; and English articles were prioritized. Meanwhile, the exclusion criteria were studies not addressing the nature of self- and family management in Indonesia, laboratory-based research using human cell and study protocol.

RESULTS

A total of 78 studies were involved in the final analysis. The facilitators and barriers, process, and outcomes (distal and proximal) were presented. The results indicated that the implementation of the self- and family management process generated favorable outcomes for the diabetes population in Indonesia.

CONCLUSIONS

The self- and family management support program is a promising strategy to improve the facilitators and overcome the barriers to diabetes care. Patients, families, diabetes nurses, and health policymakers are recommended to work in tandem to achieve successful diabetes care, particularly in the community.

Systemic Disease and Ocular Comorbidity Analysis of Geographically Isolated Federally Recognized American Indian Tribes of the Intermountain West

BACKGROUND

The American Indian Navajo and Goshute peoples are underserved patient populations residing in the Four Corners area of the United States and Ibupah, Utah, respectively.

METHODS

We conducted a cross-sectional study of epidemiological factors and lipid biomarkers that may be associated with type II diabetes, hypertension and retinal manifestations in tribal and non-tribal members in the study areas (n = 146 participants). We performed multivariate analyses to determine which, if any, risk factors were unique at the tribal level. Fundus photos and epidemiological data through standardized questionnaires were collected. Blood samples were collected to analyze lipid biomarkers. Univariate analyses were conducted and statistically significant factors at p < 0.10 were entered into a multivariate regression.

RESULTS

Of 51 participants for whom phenotyping was available, from the Four Corners region, 31 had type II diabetes (DM), 26 had hypertension and 6 had diabetic retinopathy (DR). Of the 64 participants from Ibupah with phenotyping available, 20 had diabetes, 19 had hypertension and 6 had DR. Navajo participants were less likely to have any type of retinopathy as compared to Goshute participants (odds ratio (OR) = 0.059; 95% confidence interval (CI) = 0.016-0.223; p < 0.001). Associations were found between diabetes and hypertension in both populations. Older age was associated with hypertension in the Four Corners, and the Navajo that reside there on the reservation, but not within the Goshute and Ibupah populations. Combining both the Ibupah, Utah and Four Corners study populations, being American Indian (p = 0.022), residing in the Four Corners (p = 0.027) and having hypertension (p < 0.001) increased the risk of DM. DM (p < 0.001) and age (p = 0.002) were significantly associated with hypertension in both populations examined. When retinopathy was evaluated for both populations combined, hypertension (p = 0.037) and living in Ibupah (p < 0.001) were associated with greater risk of retinopathy. When combining both American Indian populations from the Four Corners and Ibupah, those with hypertension were more likely to have DM (p < 0.001). No lipid biomarkers were found to be significantly associated with any disease state.

CONCLUSIONS

We found different comorbid factors with retinal disease outcome between the two tribes that reside within the Intermountain West. This is indicated by the association of tribe and with the type of retinopathy outcome when we combined the populations of American Indians. Overall, the Navajo peoples and the Four Corners had a higher prevalence of chronic disease that included diabetes and hypertension than the Goshutes and Ibupah. To the best of our knowledge, this is the first study to conduct an analysis for disease outcomes exclusively including the Navajo and Goshute tribe of the Intermountain West.

Expectations and fears of patients with diabetes and macular edema treated by intravitreal injections

AIMS

Clinical outcomes of diabetic macular edema (DME) have been widely described, but data on diabetic retinopathy perceptions by diabetes patients are limited. The aim of this survey was to explore the lived experience, knowledge, fears and expectations about disease, and treatment in patients with diabetes and macular edema treated with intravitreal injections (IVTI) and to characterize patient profiles.

METHODS

Cross-sectional survey including a preliminary qualitative phase (20 patients with DME, treated or treatment-naive, 5 female and 15 male, age 36-74 years) followed by a quantitative survey (116 patients treated with IVTI for DME). Data ASKIA Analyze (version 5.3.3.5) was used for descriptive statistics, and R software (version 3.4.1) for multiple correspondence analysis.

RESULTS

The qualitative phase identified the wording used by patients and information helpful to propose modalities of response in the quantitative phase. In the quantitative survey (116 patients, mean age 66.6 years), most patients were treated with anti-vascular endothelial growth factor. Overall, 71.9% reported that the disease negatively affected their daily activities and 33.1% considered that regular visits to the ophthalmologist were disrupting their life. Treatment expectations differed significantly between patients in terms of disease experience (visit and injection schedules), fears and feelings, and relationship with physicians, allowing three patient profiles to be identified: "Worried" patients (n = 45) felt isolated and were worried about the need for repeated treatment and possible side effects. They were mainly active men aged < 60 with type I diabetes (T1D) and DME diagnosed for > 2 years; "Curious" patients (n = 21) experienced insufficient support and requested more information on their disease and existing treatments. They were mainly single women aged 60-69 years; "Passive" patients (n = 50) felt sufficiently informed by their ophthalmologist and were not concerned by DME. They were older (mean age: 70 years) and mainly type 2 diabetic men.

CONCLUSIONS

Patients with diabetes and macular edema treated with IVTI form a heterogeneous group regarding fears and expectations. Different patient profiles were identified and need to be confirmed in larger studies. A better understanding of psychological profiles may optimize compliance of diabetic patients.

Rates and Predictors of Nonadherence to Postophthalmic Screening Tertiary Referrals in Patients with Type 2 Diabetes

Purpose

To determine the rates and develop an initial risk prediction model for nonadherence to post screening ophthalmic referral (PSOR) in type 2 diabetes mellitus (T2DM) patients attending a national diabetic retinopathy screening program in Singapore.

Methods

Data from 2387 patients with T2DM (mean [standard deviation] age: 66.5 [11] years; 52.5% female patients) who underwent teleophthalmic screening between 2010 and 2014 under the Singapore Integrated Diabetic Retinopathy Program were extracted from electronic medical records. All were referred for tertiary ophthalmic management at the Singapore National Eye Centre (SNEC). Nonadherence was defined as not attending the SNEC appointment within 6 months of the assigned appointment date. Regression analysis using traditional modified Poisson and conditional inference models was used to construct and evaluate the discriminative ability of the preliminary risk prediction model to identify nonadherent individuals.

Results

Nonadherence rates to PSOR was 12.7% (95% confidence interval, 11.4%–14.1%). In traditional multivariable models adjusted for sociodemographic, lifestyle, and ocular factors, nonadherent individuals had higher triglyceride levels and were less likely to have a referable eye condition (P < 0.05). This model was able to identify nonadherent individuals with an accuracy (area under the curve) of 84%. In contrast, the conditional inference model was able to achieve similar discriminative ability using only participants’ ocular health characteristics.

Conclusions

The rates of nonadherence to PSOR in Singaporean individuals with T2DM is low, with better ocular health being strongly predictive of nonadherence in our Asian population.

Translational Relevance

Our results may inform interventions to decrease nonadherence to PSOR.

Computerized Adaptive Tests: Efficient and Precise Assessment of the Patient-Centered Impact of Diabetic Retinopathy

Purpose

Evaluate efficiency, precision, and validity of RetCAT, which comprises ten diabetic retinopathy (DR) quality of life (QoL) computerized adaptive tests (CATs).

Methods

In this cross-sectional clinical study, 183 English and/or Mandarin-speaking participants with DR (mean age ± standard deviation [SD] 56.4 ± 11.9 years; 38% proliferative DR [worse eye]) were recruited from retinal clinics in Singapore. Participants answered the RetCAT tests (Symptoms, Activity Limitation, Mobility, Emotional, Health Concerns, Social, Convenience, Economic, Driving, and Lighting), which were capped at seven items each, and other questionnaires, and underwent eye tests. Our primary evaluation focused on RetCAT efficiency (i.e. standard error of measurement [SEM] ± SD achieved and time needed to complete each CAT). Secondary evaluations included an assessment of RetCAT's test precision and validity.

Results

Mean SEM across all RetCAT tests was 0.351, ranging from 0.272 ± 0.130 for Economic to 0.484 ± 0.130 for Emotional. Four tests (Mobility, Social, Convenience, and Driving) had a high level of measurement error. The median time to take each RetCAT test was 1.79 minutes, ranging from 1.12 (IQR [interquartile range] 1.63) for Driving to 3.28 (IQR 2.52) for Activity Limitation. Test precision was highest for participants at the most impaired end of the spectrum. Most RetCAT tests displayed expected correlations with other scales (convergent/divergent validity) and were sensitive to DR and/or vision impairment severity levels (criterion validity).

Conclusions

RetCAT can provide efficient, precise, and valid measurement of DR-related QoL impact. Future application of RetCAT will employ a stopping rule based on SE rather than number of items to ensure that all tests can detect meaningful differences in person abilities. Responsiveness of RetCAT to treatment interventions must also be determined.

Translational Relevance

RetCAT may be useful for measuring the patient-centered impact of DR severity and disease progression and evaluating the effectiveness of new therapies.

Efficacy and follow-up of anti-VEGF injections in diabetic macular edema in real-life practice at the Dijon university medical centre through the Save Sight Registries

PURPOSE

To evaluate the efficacy of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections (IVT) in diabetic macular edema (DME) in real-life practice using the Save Sight Registries (SSR).

MATERIAL AND METHODS

We conducted an observational, single-centre, retrospective study in the department of ophthalmology of the Dijon University Hospital. We included treatment-naive patients who presented with DME between January 2016 and December 2017. Demographic and clinical data, follow-up visits, and treatments administered were entered into the SSR, an international online ophthalmic registry. Primary endpoints were the change in best-corrected visual acuity (BCVA) and central subfield thickness (CST) from baseline to 12 and 24 months.

RESULTS

Fifty-eight eyes of 43 patients with a mean [standard deviation (SD)] age of 67.1 [9.5] years were included. Forty-one eyes completed 12 months of follow-up, and 17 eyes completed 24 months of follow up. Median [SD] baseline BCVA was 56.1 [22.9] ETDRS letters and the median [95% confidence interval (95% CI)] baseline CST was 447.9 [161.0] micrometers (μm). Median [95% CI] improvement in BCVA from baseline to months 12 and 24 were respectively, +5.6 [+0.5; +10.7] ETDRS letters and +7.7 [-2.8; +18.2] ETDRS letters. The median [95% CI] decrease in CST from baseline to months 12 and 24 were respectively, -110.9 [-154.5; -67.3] μm and -125.5 [-198.0; -53.0] μm.

CONCLUSION

Our clinical practice can be evaluated easily with the SSR system. In real life, anti-VEGF IVT are an effective treatment for DME, which result in improved BCVA and decreased CST.

Psychological, social and everyday visual impact of diabetic macular oedema and diabetic retinopathy: a systematic review

AIMS

To synthesize the evidence on the impact of diabetic retinopathy and diabetic macular oedema from the patient perspective.

METHODS

A systematic literature review was conducted using MEDLINE Complete, PsycINFO, EMBASE and AMED. We included articles investigating the impact of the condition on quality of life, symptoms, visual functioning, activities of daily living, well-being, social functioning, and financial status. The studies evaluated were observational, including cross-sectional, prospective cohort and retrospective cohort designs. Outcome data were extracted and synthesized.

RESULTS

Searches yielded 5114 publications. After screening, 85 studies were included, measuring the following outcomes: visual functioning (n=46); quality of life (n=22); well-being (n=16); functional status (n=5); work (n=4); and visual task performance (n=2). Diabetic retinopathy has a considerable impact on visual functioning and this is greater in people with greater disease severity. Diabetic retinopathy significantly limits activities including working, driving, walking and reading, and has the potential to have a negative impact on psychological well-being.

CONCLUSIONS

Diabetic retinopathy is associated with poor self-reported visual functioning, well-being, and health-related quality of life. Ability to perform basic everyday tasks appears to diminish with disease severity. Some studies suggest impaired mobility and problems with work, but there are gaps in this evidence.

The prevalence of depressive symptoms and related risk factors among diabetic patients with retinopathy attending the Jordan University Hospital

OBJECTIVES

To investigate the prevalence of depressive symptoms among diabetic patients suffering from retinopathy, and to identify crucial risk factors that affect patients' quality of life and whether social support mediates the relationship between retinopathy and depression.

METHODS

The sample comprises 155 participants with diabetic retinopathy recruited from the Jordan University Hospital during the year 2017. Arabic versions of all study tools were employed as follows: the Beck Depression Inventory; the short form of the health survey; the Berlin social support scale; ophthalmic examinations; patients' records; and a demographic questionnaire.

ANALYSES

Descriptive statistics, the Pearson correlation, linear regression using SPSS, and mediation analysis using the Sobel test were applied. In addition, the odds ratio analysis and qualitative analyses for the open-ended questions were included.

RESULTS

In general, 13 (8.9%) of our patients did not manifest any symptoms of depression while 42 (27.1%) had a mild mood disturbance, 26 (16.8%) were on the borderline of clinical depression, 47 (30.3%) had moderate depression, 22 (14.2%) with severe depression, and 5 (3.2%) had extreme depression. The results indicate a nonsignificant positive correlation between social support and health-related quality of life and a nonsignificant positive relationship between retinopathy severity and depression. Meanwhile, our results revealed a significant negative relationship between depression and social support and a nonsignificant negative relationship between retinopathy severity and social support.

CONCLUSION

Our findings suggest that diabetic patients with retinopathy have a higher risk of developing depression. Hence, psychological interventions are highly needed to meet the mental health needs of these patients.

Identification and Evaluation of Items for Vitreoretinal Diseases Quality of Life Item Banks

Purpose: We are developing item banks assessing the impact of retinal and vitreoretinal diseases (excluding age-related macular degeneration, diabetic retinopathy, and retinal detachment, covered elsewhere) on quality of life (QoL) for adults. This study outlines the first two phases of the multi-stage process: content development and item evaluation.Methods: We grouped retinal and vitreoretinal diseases into hereditary and acquired. Development of the item banks involved two phases: item identification and item evaluation. The items were extracted from three sources: (1) 17 pre-existing PRO instruments, (2) 4 qualitative studies and (3) 79 semi-structured interviews. Item evaluation involved three stages namely, binning (grouping) and winnowing (reduction), expert panel opinion and cognitive interviews.Results: The item identification phase yielded 1,217 items. After three sessions of binning and winnowing, items were reduced to a minimally representative set (n = 411) across nine QoL domains namely, activity limitation, emotional, social, health concerns, symptoms, economic, mobility, convenience, and coping. The hereditary group had a total of 345 items and the acquired group had a total of 257 items. After 23 cognitive interviews items were amended for hereditary diseases resulting in a final set of 345 items and 3 items were amended for acquired diseases, resulting in a final set of 254 items. Overall across nine domains 189 items were common to hereditary and acquired retinal and vitreoretinal diseases.Conclusion: As most of the items were unique to hereditary versus acquired retinal and vitreoretinal disease groups separate item banks are required to capture the QoL impacts for hereditary and acquired retinal and vitreoretinal diseases.

The relationship between diabetic retinopathy and psychosocial functioning: a systematic review

IMPORTANCE

Previous work has reported a link between diabetic retinopathy/diabetic macular edema (DR/DME) and psychosocial functioning, although the extent and direction of the association remains uncertain.

OBJECTIVE

To determine the relationship between DR/DME and psychosocial functioning, the latter an umbrella term used to capture the emotional and social aspects of functioning which may include, for example, depression; depressive disorder; anxiety; vision-specific distress; diabetes-specific distress and emotional and social well-being.

EVIDENCE REVIEW

PubMed, Embase, Medline and the Cochrane Central register were systematically searched for relevant interventional and observational quantitative studies using standardised criteria. Studies with DR/DME and psychosocial functioning as exposures or outcomes were accepted. Study quality was evaluated using the modified Newcastle-Ottawa scale for observational studies, and the modified Down's and Black checklist for interventional studies.

FINDINGS

Of 1827 titles initially identified, 42 were included in the systematic review. They comprised of four interventions (one RCT, three non-RCTs) and 38 observational studies (33 cross sectional, five prospective). In studies with DR/DME as the exposure (n = 28), its severity and related vision impairment were consistently associated with poor psychosocial outcomes, mostly higher incidence of depression and depressive symptoms. Baseline depression and depressive symptoms were also associated with greater DR incidence and progression of DR. Medical intervention strategies showed significant improvement in psychosocial outcomes in patients with DR, such as significant improvements in mental health domain scores of the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ 25).

CONCLUSION AND RELEVANCE

Severity of DR, DME and associated vision loss are significantly associated with poor psychosocial outcomes. Aspects of depression and its symptoms show a bi-directional association, with increased incidence and progression of DR significant in those with baseline depression or depressive symptoms. Based on these findings, we propose two areas that may benefit from targeted interventions: (1) Prevention of development of poor psychological outcomes by preventing and delaying progression of DR/DME; and (2) Improved detection and management of poor psychological functioning by improving screening tools and multidisciplinary care for patients. Subsequent longitudinal studies can further help establish the underlying relationship between the two measures.

Validation of a novel diabetic retinopathy utility index using discrete choice experiments

BACKGROUND/AIMS

To validate a preference-based Diabetic Retinopathy Utility Index (DRU-I) using discrete choice experiment (DCE) methods and assess disutilities associated with vision-threatening DR (VTDR: severe non-proliferative DR, proliferative DR and clinically significant macular oedema) and associated vision impairment.

METHODS

The DRU-I comprises five quality-of-life dimensions, including Visual symptoms, Activity limitation/mobility, Lighting and glare, Socio-emotional well-being and Inconvenience, each rated as no, some, or a lot of difficulty. The DRU-I was developed using a DCE comprising six blocks of nine choice sets which, alongside the EuroQoL-5D (EQ-5D-3L) and Vision and Quality of Life (VisQoL) utility instruments, were interviewer-administered to participants. To ensure the DRU-I was sensitive to severe disease, we oversampled patients with VTDR. Data were analysed using conditional logit regression.

RESULTS

Of the 220 participants (mean±SD age 60.1±11.3 years; 70.9% men), 57 (29.1%) and 139 (70.9%) had non-VTDR and VTDR, respectively, while 157 (71.4%), 20 (9.4%) and 37 (17.3%) had no, mild or moderate/severe vision impairment, respectively. Regression coefficients for all dimensions were ordered as expected, with worsening levels in each dimension being less preferred (theoretical validity). DRU-I utilities decreased as DR severity (non-VTDR=0.87; VTDR=0.80; p=0.021) and better eye vision impairment (none=0.84; mild=0.78; moderate/severe=0.72; p=0.012) increased. DRU-I utilities had low (r=0.39) and moderate (r=0.58) correlation with EQ-5D and VisQoL utilities, respectively (convergent validity).

DISCUSSION

The DRU-I can estimate utilities associated with vision-threatening DR and associated vision impairment. It has the potential to assess the cost-effectiveness of DR interventions from a patient perspective and inform policies on resource allocation relating to DR.

Treatment of Diabetes in Older Adults: An Endocrine Society* Clinical Practice Guideline

OBJECTIVE

The objective is to formulate clinical practice guidelines for the treatment of diabetes in older adults.

CONCLUSIONS

Diabetes, particularly type 2, is becoming more prevalent in the general population, especially in individuals over the age of 65 years. The underlying pathophysiology of the disease in these patients is exacerbated by the direct effects of aging on metabolic regulation. Similarly, aging effects interact with diabetes to accelerate the progression of many common diabetes complications. Each section in this guideline covers all aspects of the etiology and available evidence, primarily from controlled trials, on therapeutic options and outcomes in this population. The goal is to give guidance to practicing health care providers that will benefit patients with diabetes (both type 1 and type 2), paying particular attention to avoiding unnecessary and/or harmful adverse effects.

A qualitative exploration of the effect of visual field loss on daily life in home-dwelling stroke survivors

OBJECTIVE

To explore the effect of visual field loss on the daily life of community-dwelling stroke survivors.

DESIGN

A qualitative interview study.

PARTICIPANTS

Adult stroke survivors with visual field loss of at least six months' duration.

METHODS

Semi-structured interviews were conducted with a non-purposive sample of 12 stroke survivors in their own homes. These were recorded, transcribed verbatim and analyzed with the framework method, using an inductive approach.

RESULTS

Two key analytical themes emerged. 'Perception, experience and knowledge' describes participant's conflicted experience of having knowledge of their impaired vision but lacking perception of that visual field loss and operating under the assumption that they were viewing an intact visual scene when engaged in activities. Inability to recognize and deal with visual difficulties, and experiencing the consequences, contributed to their fear and loss of self-confidence. 'Avoidance and adaptation' were two typologies of participant response to visual field loss. Initially, all participants consciously avoided activities. Some later adapted to vision loss using self-directed head and eye scanning techniques.

CONCLUSIONS

Visual field loss has a marked impact on stroke survivors. Stroke survivors lack perception of their visual loss in everyday life, resulting in fear and loss of confidence. Activity avoidance is a common response, but in some, it is replaced by self-initiated adaptive techniques.

Understanding quality of life impact in people with retinal vein occlusion: a qualitative inquiry

BACKGROUND

Although being the second most common sight-threatening retinal vascular disease after diabetic retinopathy, the patient-centred impact of retinal vein occlusion has not been well studied. This study aims to understand the quality of life issues in people with retinal vein occlusion using a qualitative methodology.

METHODS

In-depth semi-structured interviews were conducted with 17 patients with retinal vein occlusion. All the interviews were digitally recorded and transcribed verbatim. An inductive analytic approach based on the constant comparative method was used for coding, aggregation, and theme development. The qualitative analysis was done using the software NVivo.

RESULTS

Participants had a median age of 73 years (range 34-85 years; females, 71 per cent). Six quality of life themes were identified: concerns about the disease progression and treatment outcome (health concerns), emotional responses to the disease (emotional), experiencing a range of symptoms (symptoms), inability to do things as before (activity limitation), adapting to the visual loss (coping), and inconveniences due to the eye condition (convenience). Participants often felt that lasers and injections did not improve their vision. They feared that their eye condition may come back, or the other eye may be affected. They experienced a range of visual symptoms that affected their day-to-day performance, particularly reading small print, and driving at night. Having multiple treatments and frequent eye appointments were major sources of inconvenience. Patients adopted several coping strategies to manage the stress associated with visual loss.

CONCLUSIONS

This study shows that several aspects of quality of life are compromised in people with retinal vein occlusion. The findings of this study will be used to identify the item content for a vitreoretinal disease-specific quality of life item bank.

The use of patient-reported outcome research in modern ophthalmology: impact on clinical trials and routine clinical practice

This review article considers the rising demand for patient-reported outcome measures (PROMs) in modern ophthalmic research and clinical practice. We review what PROMs are, how they are developed and chosen for use, and how their quality can be critically appraised. We outline the progress made to develop PROMs in each clinical subspecialty. We highlight recent examples of the use of PROMs as secondary outcome measures in randomized controlled clinical trials and consider the impact they have had. With increasing interest in using PROMs as primary outcome measures, particularly where interventions have been found to be of equivalent efficacy by traditional outcome metrics, we highlight the importance of instrument precision in permitting smaller sample sizes to be recruited. Our review finds that while there has been considerable progress in PROM development, particularly in cataract, glaucoma, medical retina, and low vision, there is a paucity of useful tools for less common ophthalmic conditions. Development and validation of item banks, administered using computer adaptive testing, has been proposed as a solution to overcome many of the traditional limitations of PROMs, but further work will be needed to examine their acceptability to patients, clinicians, and investigators.

Impact of Incidence and Progression of Diabetic Retinopathy on Vision-Specific Functioning

PURPOSE

To investigate the independent impact of the incidence and progression of diabetic retinopathy (DR) on visual functioning (VF).

DESIGN

Population-based cohort study.

PARTICIPANTS

A total of 518 participants aged 40 to 80 years (baseline visit 2007-2009 and second visit 6 years later, 2013-2015), with diabetes, clinical data, and VF information at both visits.

MAIN OUTCOME MEASURES

VF-7 scores, converted to interval-level person measures (in logits) using Rasch analysis.

METHODS

Incident DR was defined using the Modified Airlie House classification as "none or minimal" DR at baseline and at least mild nonproliferative DR at follow-up; incident vision-threatening DR (VTDR; severe nonproliferative DR, proliferative DR, and/or clinically significant macular edema) as no VTDR at baseline, and present at follow-up; and DR progression as at least a 1-step worsening in DR at follow-up from mild or worse status at baseline. The longitudinal associations between incident DR, VTDR, and DR progression, as well as change in composite and individual item scores of VF, were assessed using multivariable linear regression models.

RESULTS

Of the 518 participants (mean age ± standard deviation [SD] 59.8±9.0 years; 47.7% female), 42 (9.8%), 14 (2.8%), and 32 (42.7%) had incident DR, incident VTDR, and DR progression, respectively, at follow-up. In models adjusting for traditional confounders, persons with incident DR and VTDR had a 13.7% (β = -0.60; 95% confidence interval [CI], -0.96 to -0.24; P = 0.001) and 23% (β = -1.00; 95% CI, -1.61 to -0.38; P = 0.001) reduction in mean VF scores at follow-up. Furthermore, individuals with incident DR had similar independent reductions in scores for 7 individual items of the VF-7, whereas those with incident VTDR had the largest reductions for activities like cooking (31%; P = 0.003), reading the newspaper (29.6%; P < 0.001), and seeing street signs (28%, P = 0.001) at follow-up. Progression of DR was not independently associated with change in overall VF (β = -0.18; 95% CI, -1.00, 0.64; P = 0.660).

CONCLUSIONS

Incident DR, particularly vision-threatening stages, has a substantial negative impact on people's overall vision-dependent functioning and specific activities such as cooking, seeing street signs, and reading the newspaper. Our findings reinforce the need for strategies to prevent or delay the development of DR.

Accuracy of fundus autofluorescence imaging for the diagnosis and monitoring of retinal conditions: a systematic review

BACKGROUND

Natural fluorescence in the eye may be increased or decreased by diseases that affect the retina. Imaging methods based on confocal scanning laser ophthalmoscopy (cSLO) can detect this 'fundus autofluorescence' (FAF) by illuminating the retina using a specific light 'excitation wavelength'. FAF imaging could assist the diagnosis or monitoring of retinal conditions. However, the accuracy of the method for diagnosis or monitoring is unclear.

OBJECTIVE

To conduct a systematic review to determine the accuracy of FAF imaging using cSLO for the diagnosis or monitoring of retinal conditions, including monitoring of response to therapy.

DATA SOURCES

Electronic bibliographic databases; scrutiny of reference lists of included studies and relevant systematic reviews; and searches of internet pages of relevant organisations, meetings and trial registries. Databases included MEDLINE, EMBASE, The Cochrane Library, Web of Science and the Medion database of diagnostic accuracy studies. Searches covered 1990 to November 2014 and were limited to the English language.

REVIEW METHODS

References were screened for relevance using prespecified inclusion criteria to capture a broad range of retinal conditions. Two reviewers assessed titles and abstracts independently. Full-text versions of relevant records were retrieved and screened by one reviewer and checked by a second. Data were extracted and critically appraised using the Quality Assessment of Diagnostic Accuracy Studies criteria (QUADAS) for assessing risk of bias in test accuracy studies by one reviewer and checked by a second. At all stages any reviewer disagreement was resolved through discussion or arbitration by a third reviewer.

RESULTS

Eight primary research studies have investigated the diagnostic accuracy of FAF imaging in retinal conditions: choroidal neovascularisation (one study), reticular pseudodrusen (three studies), cystoid macular oedema (two studies) and diabetic macular oedema (two studies). Sensitivity of FAF imaging using an excitation wavelength of 488 nm was generally high (range 81-100%), but was lower (55% and 32%) in two studies using longer excitation wavelengths (514 nm and 790 nm, respectively). Specificity ranged from 34% to 100%. However, owing to limitations of the data, none of the studies provide conclusive evidence of the diagnostic accuracy of FAF imaging.

LIMITATIONS

No studies on the accuracy of FAF imaging for monitoring the progression of retinal conditions or response to therapy were identified. Owing to study heterogeneity, pooling of diagnostic outcomes in meta-analysis was not conducted. All included studies had high risk of bias. In most studies the patient spectrum was not reflective of those who would present in clinical practice and no studies adequately reported how FAF images were interpreted.

CONCLUSIONS

Although already in use in clinical practice, it is unclear whether or not FAF imaging is accurate, and whether or not it is applied and interpreted consistently for the diagnosis and/or monitoring of retinal conditions. Well-designed prospective primary research studies, which conform to the paradigm of diagnostic test accuracy assessment, are required to investigate the accuracy of FAF imaging in diagnosis and monitoring of inherited retinal dystrophies, early age-related macular degeneration, geographic atrophy and central serous chorioretinopathy.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014014997.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The association between bouted and non-bouted physical activity on retinopathy prevalence

OBJECTIVE

We evaluated the specific differential association between non-bouted, lifestyle physical activities (vs. structured exercise; i.e., bouted physical activity) on retinopathy prevalence among a national sample of the broader U.S. adult population.

METHODS

Data from the 2005-2006 National Health and Nutrition Examination Survey (NHANES) was used to identify 1501 adults, between 40 and 85years. Bouted and non-bouted physical activities were assessed using objective accelerometer monitoring. A 10-minute bout was defined as 10+ consecutive minutes above the moderate-to-vigorous physical activity (MVPA) cut-point, with the allowance of 1-2-minute interruption intervals. Non-bout MVPA was determined by the number of MVPA minutes not accrued in a bout. Participants were screened for non-proliferative retinopathy using Early Treatment Diabetic Retinopathy Study grading criteria, as well as objective retinal imaging assessments using the Canon Non-Mydriatic Retinal Camera CR6-45NM. Individuals were excluded if they had been diagnosed with coronary artery disease, congestive heart failure, heart attack or stroke.

RESULTS

Participants with worse retinopathy engaged in less bouted and non-bouted physical activity, had a higher BMI and were more likely to have diabetes and hypertension. For every 1min/day increase in non-bouted MVPA, participants had a 7% reduced odds of moderate-to-severe retinopathy compared to no retinopathy (OR=0.93; 95% CI: 0.87-0.99; P=0.04); results were similar in an unadjusted model (OR=0.93; 95% CI: 0.89-0.97; P=0.007). Bouted MVPA was not associated with retinopathy prevalence in the multivariate model.

CONCLUSION

In this nationally representative sample of adults, those who engaged in non-bouted physical activity had reduced odds of a diagnosis of moderate-to-severe retinopathy.