Impact of age-related macular degeneration on vision-specific quality of life: Follow-up from the 10-year and 15-year visits of the Study of Osteoporotic Fractures

Relationships between Patient-Reported Outcome Measures and Clinical Measures in Naïve Neovascular Age-Related Macular Degeneration Patients Treated with Intravitreal Ranibizumab

Our objective was to evaluate changes in patient-reported outcome measures using the NEI-VFQ 25 questionnaire during a treat and extend regimen in naive neovascular Age-Related Macular Degeneration patients, and its correlation with anatomical and functional data. We conducted a prospective observational study. Patients underwent a treat and extend regimen with intravitreal ranibizumab for neovascular Age-Related Macular Degeneration. Initial response was evaluated at 4th month, and subsequently in every follow-up visit. If a clinical response was achieved, the injection interval was extended in two-week increments, up to a maximum of 12 weeks. Quality of life was assessed using the NEI-VFQ 25 questionnaire at baseline, 4th months, and 12th months. Patients were categorized as good or poor responders based on Best corrected visual acuity, central foveal thickness, intraretinal fluid, or subretinal fluid. Treatment with ranibizumab led to a significant improvement in quality of life, with a mean increase in NEI-VFQ 25 score of 4.27 points in the 12th month. No significant differences in improvement were observed between good and poor responders. Quality of life scores in neovascular Age-Related Macular Degeneration patients improved with intravitreal treatment regardless of the clinical response. The early response following the loading phase could indicate better quality of life after one year of treatment, with Best corrected visual acuity being the clinical parameter with the greatest influence on quality of life.

Role of Complement in the Onset of Age-Related Macular Degeneration

Age-related macular degeneration (AMD) is a progressive degenerative disease of the central retina and the leading cause of severe loss of central vision in people over age 50. Patients gradually lose central visual acuity, compromising their ability to read, write, drive, and recognize faces, all of which greatly impact daily life activities. Quality of life is significantly affected in these patients, and there are worse levels of depression as a result. AMD is a complex, multifactorial disease in which age and genetics, as well as environmental factors, all play a role in its development and progression. The mechanism by which these risk factors interact and converge towards AMD are not fully understood, and therefore, drug discovery is challenging, with no successful therapeutic attempt to prevent the development of this disease. In this review, we describe the pathophysiology of AMD and review the role of complement, which is a major risk factor in the development of AMD.

The impact of advanced age-related macular degeneration on the National Eye Institute's Visual Function Questionnaire-25

PURPOSE

To assess visual function among patients diagnosed with age-related macular degeneration (AMD) by stage of disease and laterality.

METHODS

This is a cross-sectional cohort study of 739 AMD patients and their responses to the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25) at time of study enrolment. Patients with AMD were categorized into Early/Intermediate AMD and three groups of advanced AMD: (i) neovascular AMD (NV), (ii) geographic atrophy (GA) and (iii) Both Advanced forms. These three advanced stages were further stratified into unilateral or bilateral advanced disease. Mean composite scores and subscale scores for 12 different areas were based on a 100-point scale with the lowest and highest possible scores set at 0 and 100, respectively. Scores for the advanced AMD groups were compared with Early/Intermediate AMD using general linear modelling.

RESULTS

A total of 739 AMD patients (294 Early/Intermediate, 115 GA, 168 NVAMD and 162 Both Advanced) were included in the analysis. Mean composite scores were highest among Early/Intermediate patients (89.9), followed by patients diagnosed with unilateral disease in the Both Advanced (88.0) and NV (86.1) groups. Mean composite scores were similar for bilateral NV (82.9) and unilateral GA (81.7), and mean scores were lowest for the bilateral GA (71.3) and bilateral Both Advanced (68.5) groups. In general, this pattern persisted across the twelve subscales as well. Subscale scores ranged from a low of 35.1 for driving among bilateral Both Advanced patients to a high of 99.2 for colour vision among patients with unilateral Both Advanced. Overall, patients with unilateral advanced disease consistently had higher mean scores than their bilateral counterparts. The largest difference was 19.5 composite score points between the unilateral and bilateral Both Advanced groups, there was a difference of 10.4 points between the GA groups, and a relatively small difference of 3.2 points between the NV groups.

CONCLUSIONS

We found large differences in visual function as reported from the VFQ-25 across the different types of advanced stage AMD groups and number of eyes affected with advanced AMD. These findings demonstrate the importance of accounting for the type and number of eyes affected by advanced stage AMD.

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

Manhattan Vision Screening and Follow-up Study in Vulnerable Populations (NYC-SIGHT): Design and Methodology

PRCIS

The Manhattan Vision Screening and Follow-up Study in Vulnerable Populations is a 5-year prospective, cluster-randomized study to improve detection and management of glaucoma and other eye diseases in vulnerable populations living in affordable housing developments.

PURPOSE

To describe the study design and methodology of the Manhattan Vision Screening and Follow-up Study in Vulnerable Populations, which aims to investigate whether community-based vision screenings can improve detection and management of glaucoma, vision impairment, cataract, and other eye diseases among vulnerable populations living in affordable housing developments in upper Manhattan.

MATERIALS AND METHODS

This 5-year prospective, cluster-randomized, controlled trial consists of vision screening and referral for follow-up eye care among eligible residents aged 40 and older. Visual acuity, intraocular pressure (IOP), and fundus photography are measured. Participants with visual worse than 20/40, or IOP 23 to 29 mm Hg, or unreadable fundus images fail the screening and are scheduled with the on-site optometrist. Those with an abnormal image and/or IOP ≥30 mm Hg, are assigned as "fast-track" and referred to ophthalmology. Participants living in 7 developments randomized to the Enhanced Intervention Group who fail the screening and need vision correction receive complimentary eyeglasses. Those referred to ophthalmology receive enhanced support with patient navigators to assist with follow-up eye care. Participants living in 3 developments randomized to the Usual Care Group who fail the screening and need vision correction are given an eyeglasses prescription only and a list of optical shops. No enhanced support is given to the Usual Care Group. All participants referred to ophthalmology are assisted in making their initial eye exam appointment.

CONCLUSION

This study targets vulnerable populations where they live to ensure improved access to and utilization of eye care services in those who are least likely to seek eye care.

The complement system in age-related macular degeneration

Age-related macular degeneration (AMD) is a chronic and progressive degenerative disease of the retina, which culminates in blindness and affects mainly the elderly population. AMD pathogenesis and pathophysiology are incredibly complex due to the structural and cellular complexity of the retina, and the variety of risk factors and molecular mechanisms that contribute to disease onset and progression. AMD is driven by a combination of genetic predisposition, natural ageing changes and lifestyle factors, such as smoking or nutritional intake. The mechanism by which these risk factors interact and converge towards AMD are not fully understood and therefore drug discovery is challenging, where no therapeutic attempt has been fully effective thus far. Genetic and molecular studies have identified the complement system as an important player in AMD. Indeed, many of the genetic risk variants cluster in genes of the alternative pathway of the complement system and complement activation products are elevated in AMD patients. Nevertheless, attempts in treating AMD via complement regulators have not yet been successful, suggesting a level of complexity that could not be predicted only from a genetic point of view. In this review, we will explore the role of complement system in AMD development and in the main molecular and cellular features of AMD, including complement activation itself, inflammation, ECM stability, energy metabolism and oxidative stress.

Impact of incident age-related macular degeneration and associated vision loss on vision-related quality of life

BACKGROUND

We examined the associations between the 6-year incidence of age-related macular degeneration (AMD) and vision-related quality of life (VRQoL), and the contribution of presenting visual acuity (VA), in an Asian population.

METHODS

Fundus images from the Singapore Chinese Eye Study, a population-based cohort study (baseline: 2009-2011; follow-up: 2015-2017), were graded using a modified Wisconsin age-related maculopathy grading system. Incident AMD was defined as no baseline AMD in both eyes and early/late AMD in the worse eye at follow-up. Presenting VA was assessed using the logarithm of the minimum angle of resolution chart at 4 m under standard lighting conditions with habitual correction. Multiple linear regression models determined the associations between AMD incidence with changes in the Rasch-transformed scores of the Reading, Mobility and Emotional VRQoL domains of the 32-item Impact of Visual Impairment (IVI-32) questionnaire, adjusted for traditional confounders. The contribution of presenting VA to changes in VRQoL was also estimated.

RESULTS

Of the 2251 participants without AMD at baseline (mean age (SD): 57.7 (9) years, 51.4% women), 101 (4.5%) and 11 (0.5%) developed incident early and late AMD at follow-up, respectively. Incident late AMD was associated with significant 30.3%, 32.5% and 30.9% decrements in Reading, Mobility and Emotional IVI scores, respectively. The contribution of presenting VA ranged between 1.62% and 4.35% of the observed decrements. No significant associations were noted with incident early AMD.

CONCLUSION

Incident late AMD had a substantial impact on all aspects of VRQoL, with presenting VA contributing only minimally to this longitudinal relationship.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Translational Relevance

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

Age-Related Macular Degeneration: Epidemiology and Clinical Aspects

Age-related macular degeneration (AMD) is a degenerative disease of the human retina affecting individuals over the age of 55 years. This heterogeneous condition arises from a complex interplay between age, genetics, and environmental factors including smoking and diet. It is the leading cause of blindness in industrialized countries. Worldwide, the number of people with AMD is predicted to increase from 196 million in 2020 to 288 million by 2040. By this time, Asia is predicted to have the largest number of people with the disease. Distinct patterns of AMD prevalence and phenotype are seen between geographical areas that are not explained fully by disparities in population structures. AMD is classified into early, intermediate, and late stages. The early and intermediate stages, when visual symptoms are typically absent or mild, are characterized by macular deposits (drusen) and pigmentary abnormalities. Through risk prediction calculators, grading these features helps predict the risk of progression to late AMD. Late AMD is divided into neovascular and atrophic forms, though these can coexist. The defining lesions are macular neovascularization and geographic atrophy, respectively. At this stage, visual symptoms are often severe and irreversible, and can comprise profoundly decreased central vision in both eyes. For these reasons, the condition has major implications for individuals and society, as affected individuals may experience substantially decreased quality of life and independence. Recent advances in retinal imaging have led to the recognition of an expanded set of AMD phenotypes, including reticular pseudodrusen, nonexudative macular neovascularization, and subtypes of atrophy. These developments may lead to refinements in current classification systems.

Determinants of concern about falling in adults with age-related macular degeneration

PURPOSE

To investigate the prevalence and level of concern about falling (CF) among older people with vision impairment due to age-related macular degeneration (AMD) compared to a visually normal control group, and to identify determinants of CF for the AMD group.

METHODS

Participants included 133 older people: 77 with AMD (mean age = 80.5 ± 6.2 years), and 56 controls (mean age = 75.4 ± 5.3 years). Binocular visual acuity, contrast sensitivity and visual fields were measured, and CF was assessed using the Falls Efficacy Scale - International (FES-I). Data were also collected for sensorimotor function (postural sway, sit-to-stand, knee extensions, walking speed, proprioception), and neuropsychological function (reaction time, symptoms of anxiety and depression) using validated tests and scales.

RESULTS

Concern about falling scores were higher for AMD participants compared to control participants (mean ± S.D. 24.6 ± 8.0 vs 21.6 ± 5.7, p = 0.02, respectively), although these findings failed to reach significance when adjusted for age (p = 0.16). Among AMD participants, multivariable models showed that greater CF was associated with reduced contrast sensitivity (p = 0.02), slower sit-to-stand times (p < 0.001) and higher anxiety scores (p < 0.001); these factors explained 40% of the variance in CF (p < 0.01).

CONCLUSION

Levels of CF in older people with AMD were not found to be elevated by their disease status alone, but rather by the extent of vision loss. Levels of CF in those with AMD were associated with various visual, sensorimotor and neuropsychological factors. These findings will assist clinicians in identifying those at greatest risk of developing high CF and inform the design of future intervention programmes for this population.

Living arrangements and quality of life among older adults in China: does social cohesion matter?

Objectives: This study investigated how living arrangements are related to the well-being of Chinese older adults and the role of social cohesion in this relationship. Methods: This study used the China data from the WHO's Study on Global AGEing and Adult Health. The analytic sample featured 5,600 Chinese adults aged 60 or older. The study conceptualized two sets of models: social cohesion as mediators and as moderators in the relationship of living arrangements and quality of life. Results: Results from structural equation modelling analyses show that Chinese older adults who lived with adult children had lower quality of life scores compared with those who did not live with adult children; the negative relationship was partially mediated through decreased social cohesion. The study also found social cohesion may buffer the negative influence of not living with a spouse compared with those who did. Conclusion: This study sheds light on the mediating and moderating effects of social cohesion on the relationship between living arrangement and quality of life among older adults in China. The findings indicate the necessity of promoting social connectedness and neighborhood cohesion for older Chinese, especially those who live with their adult children.

Predictors of health-related quality of life in Chinese patients receiving treatment for neovascular age-related macular degeneration: a prospective longitudinal study

Background

Age-related macular degeneration (AMD) is currently the leading cause of irreversible visual impairment in developed countries and seriously affects the health-related quality of life (HRQoL) of patients. However, the majority of the research in this area employs cross-sectional design; longitudinal research investigating changes in HRQoL and influencing factors is limited. The aim of this study was to use a longitudinal study design to investigate descriptive trends in HRQoL and their predictive factors in Chinese AMD patients receiving treatment with vascular endothelial growth factor inhibitors (anti-VEGF) at baseline and follow-ups.

Methods

In a sample of 142 AMD patients from the outpatient clinic of the Southwest Eye Hospital, a tertiary major hospital in the southwest of China, each patient completed a self-administered questionnaire assessing demographics, clinical features, HRQoL, depression, anxiety, coping style, social support, and self-efficacy at baseline and at 1-, 3-, 6-, and 12-month follow-up appointments.

Results

The total score of HRQoL fluctuated, with the highest score at the 6-month follow-up and the lowest score at baseline. Multivariable linear regression showed the predictors of HRQoL are best-corrected visual acuity (BCVA), income level, depression, and visual acuity (VA) of the treated eye at baseline; BCVA, income, and depression at the 1-month follow-up; duration, area of residence, gender, VA of the treated eye, BCVA, income, anxiety, social support, self-efficacy, and depression at the 3-month follow-up; gender, BCVA, income, anxiety, social support, self-efficacy, depression, negative coping, and positive coping at the 6-month follow-up; and BCVA, social support, self-efficacy, and depression at the 12-month follow-up.

Conclusions

The HRQoL and its predictive factors in Chinese AMD patients receiving anti-VEGF treatment fluctuated over time. It is suggested that medical staff should get more information when planning precise care for improving patients’ HRQoL.

Domains of health-related quality of life in age-related macular degeneration: a qualitative study in the Chinese cultural context

OBJECTIVE

To explore which areas of health-related quality of life were affected in Chinese patients, and to identify whether the areas are well covered by validated questionnaires.

DESIGN

A qualitative study based on semistructured interviews was conducted. A qualitative thematic analysis following the approach of Colaizzi was used to analyse the interview data for significant statements and phrases. The themes and subthemes organised from the analysis were then compared by using the following current instruments: National Eye Institute Visual Function Questionnaire (NEI-VFQ-25), Macular Disease Quality of life Questionnaire (MacDQoL) and Low-Luminance Questionnaire (LLD).

PARTICIPANTS AND SETTING

Twenty-one patients with age-related macular degeneration were recruited from the eye clinic of Southwest Eye Hospital in Chongqing, mainland China.

RESULTS

The mean age of the participants was 69.8 years (range 57-82 years) and the duration of the disease ranged from 3 months to 6 years. The qualitative analysis revealed nine important domains including symptoms, difficulties with daily activities, depending on others, depression and uncertainty, optimism and hope, social isolation, role change, family support and financial burden. However, all the three questionnaires were insufficient to capture the full extent of quality of life issues of Chinese patients with AMD, and MacDQoL covered more domains when compared with NEI-VFQ-25 and LLD.

CONCLUSION

The domains of concepts important to people with AMD in the Chinese culture are not fully represented in the three widely used questionnaires. Nine important domains were identified for the assessment of quality of life and should be considered when assessing the impact of AMD on Chinese individuals. Further studies are needed to develop an AMD quality of life questionnaire, better tailored to the needs and culture of Chinese patients.

NATURAL COURSE OF PATIENTS DISCONTINUING TREATMENT FOR AGE-RELATED MACULAR DEGENERATION AND FACTORS ASSOCIATED WITH VISUAL PROGNOSIS

PURPOSE

To evaluate the 24-month natural course of visual changes in patients discontinuing treatment despite persistent or recurrent fluid and factors predictive of visual prognosis.

METHODS

This retrospective, observational study included 35 patients (35 eyes) who initially received anti-vascular endothelial growth factor treatment for neovascular age-related macular degeneration (AMD), but discontinued treatment despite persistent or recurrent fluid. The best-corrected visual acuity (BCVA) at treatment discontinuation was determined and compared with the 24-month BCVA, which was then compared between polypoidal choroidal vasculopathy and other neovascular age-related macular degeneration subtypes. Baseline characteristics predictive of visual outcome and the degree of visual change were also analyzed.

RESULTS

The mean number of anti-vascular endothelial growth factor injections before treatment discontinuation was 4.0 ± 1.6. The mean logarithm of minimal angle of resolution of BCVA at treatment discontinuation and that at 24 months were 1.02 ± 0.20 (Snellen equivalents = 20/209) and 1.60 ± 0.56 (20/796), respectively (P < 0.001). The 24-month BCVA was not different between polypoidal choroidal vasculopathy and other neovascular age-related macular degeneration subtypes (P = 0.803). The type of fluid (intraretinal fluid vs. no intraretinal fluid) was predictive of 24-month BCVA (P = 0.004) and the degree of changes in BCVA (P = 0.043).

CONCLUSION

Marked deterioration in visual acuity was noted in patients discontinuing treatment, regardless of neovascular age-related macular degeneration subtypes. The presence of intraretinal fluid was associated with worse visual prognosis, suggesting that patients with intraretinal fluid should be strongly warned about their poor prognosis before they decide to discontinue treatment.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Artemisinin Protects Retinal Neuronal Cells against Oxidative Stress and Restores Rat Retinal Physiological Function from Light Exposed Damage

Oxidative stress plays a key role in the pathogenesis of age-related macular degeneration (AMD), a leading cause of severe visual loss and blindness in the aging population which lacks any effective treatments currently. In this study, artemisinin, a well-known antimalarial drug was found to suppress hydrogen peroxide (H₂O₂)-induced cell death in retinal neuronal RGC-5 cells. Artemisinin, in the therapeutically relevant dosage, concentration-dependently attenuated the accumulation of intracellular reactive oxygen species (ROS), increased mitochondrial membrane potential and decreased cell apoptosis in RGC-5 cells induced by H₂O₂. Western blot analysis showed that artemisinin upregulated the phosphorylation of p38 and extracellular signal-regulated kinases1/2 (ERK1/2) and reversed the inhibitory effect of H₂O₂ on the phosphorylation of these two kinases. Moreover, protective effect of artemisinin was blocked by the p38 kinase inhibitor PD169316 or ERK1/2 kinase pathway inhibitor PD98059, respectively. In contrast, c-Jun N-terminal kinase inhibitor and rapamycin had no effect in the protective effect of artemisinin. Taken together, these results demonstrated that artemisinin promoted the survival of RGC-5 cells from H₂O₂ toxicity via the activation of the p38 and ERK1/2 pathways. Interestingly, intravitreous injection of artimisinin, concentration-dependently reversed light exposed-damage (a dry AMD animal model) of rat retinal physiological function detected by flash electroretinogram. These results indicate that artemisinin can protect retinal neuronal functions from H₂O₂-induced damage in vitro and in vivo and suggest the potential application of artemisinin as a new drug in the treatment of retinal disorders like AMD.

DISCORDANCE BETWEEN BLUE-LIGHT AUTOFLUORESCENCE AND NEAR-INFRARED AUTOFLUORESCENCE IN AGE-RELATED MACULAR DEGENERATION

PURPOSE

To identify the origin and significance of discordance between blue-light autofluorescence (BL-AF; 488 nm) and near-infrared autofluorescence (NI-AF; 787 nm) in patients with age-related macular degeneration (AMD).

METHODS

A total of 86 eyes of 59 patients with a diagnosis of AMD were included in this cross-sectional study conducted between March 9, 2015 and May 1, 2015. A masked observer examined the BL-AF, NI-AF, and spectral-domain optical coherence tomography images. Areas with discordance of autofluorescence patterns between NI-AF and BL-AF images were correlated with structural findings at the corresponding location in optical coherence tomography scans.

RESULTS

Seventy-nine eyes had discordance between BL-AF and NI-AF. The most common optical coherence tomography finding accounting for these discrepancies was pigment migration accounting for 35 lesions in 21 eyes. The most clinically relevant finding was geographic atrophy missed on BL-AF in 7 eyes.

CONCLUSION

Our findings indicate that variations in the distribution of lipofuscin, melanin and melanolipofuscin account for the majority of discordance between BL-AF and NI-AF. Given our finding of missed geographic atrophy lesions on BL-AF in 24% of eyes with geographic atrophy (7/29 eyes), clinicians should consider multimodal imaging, including NI-AF and optical coherence tomography, especially in clinical trials of geographic atrophy.

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

OBJECTIVES

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

DESIGN

Systematic review.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Artemisinin protects human retinal pigment epithelial cells from hydrogen peroxide-induced oxidative damage through activation of ERK/CREB signaling

The pathological increase in the levels of reactive oxygen species (ROS) in the retinal pigment epithelium (RPE), is implicated in the development of age-related macular degeneration (AMD). The discovery of drug candidates to effectively protect RPE cells from oxidative damage is required to resolve the pathological aspects and modify the process of AMD. In this study, a FDA-approved anti-malaria drug, Artemisinin was found to suppress hydrogen peroxide (H2O2)-induced cell death in human RPE cell-D407 cells. Further study showed that Artemisinin significantly suppressed H2O2- induced D407 cell death by restoring abnormal changes in nuclear morphology, intracellular ROS, mitochondrial membrane potential and apoptotic biomarkers. Western blotting analysis showed that Artemisinin was able to activate extracellular regulated ERK/CREB survival signaling. Furthermore, Artemisinin failed to suppress H2O2-induced cytotoxicity and the increase of caspase 3/7 activity in the presence of the ERK inhibitor PD98059. Taken together, these results suggest that Artemisinin is a potential protectant with the pro-survival effects against H2O2 insult through activation of the ERK/CREB pathway.

The Impact of Vision Impairment (IVI) Questionnaire; Validation of the Thai-Version and the Implementation on Vision-Related Quality of Life in Thai Rural Community

The objective of this study is to validate the Thai-version of the impact of vision impairment (IVI) questionnaire and to evaluate its impact on vision-related quality of life (VRQoL) in southern Thailand. The IVI questionnaire was translated into Thai according to WHO translation guidelines. In addition to the routine ophthalmological examinations, a Thai version of the IVI questionnaire was administered to all participants. A total of 120 patients with visual impairment who presented at Songklanagarind hospital, Songkhla province, were enrolled in the study; 30 had age-related macular degeneration (AMD), 30 had cataract, 30 had diabetic retinopathy, 30 had glaucoma, and 30 non-visually impaired individuals comprised the control group. Statistical analysis demonstrated the Thai-version IVI questionnaire is valid and reliable to evaluate the VRQoL of the Thai patients through three subscales: (i) mobility and independence, (ii) reading and accessing information, and (iii) emotional well-being. The results demonstrated high consistency in all subscales with Cronbach’s alpha ranging from 0.787 to 0.849. Rasch analysis revealed the validity of the Thai-version IVI to assess VRQoL through all three subscales. Test-retest reliability was also high (intraclass correlation coefficient = 0.96). The composite score of the IVI was significantly higher in participants with visual impairment compared with healthy participants. Moreover, the subscale scores of reading and accessing information, and emotional well-being were highest in participants with AMD. While the subscale scores of mobility and independence were highest among those with either cataracts or diabetic retinopathy. The symptoms of the common vision impairment diseases are associated with an adverse impact on VRQoL in a clinic-based population as demonstrated in this study.

Diffusion of anti-VEGF injections in the Portuguese National Health System

OBJECTIVES

To analyse the temporal and geographical diffusion of antivascular endothelial growth factor (anti-VEGF) interventions, and its determinants in a National Health System (NHS).

SETTING

NHS Portuguese hospitals.

PARTICIPANTS

All inpatient and day cases related to eye diseases at all Portuguese public hospitals for the period 2002-2012 were selected on the basis of four International Classification of Diseases 9th revision, Clinical Modification (ICD-9-CM) codes for procedures: 1474, 1475, 1479 and 149.

PRIMARY AND SECONDARY OUTCOME MEASURES

We measured anti-VEGF treatment rates by year and county. The determinants of the geographical diffusion were investigated using generalised linear modelling.

RESULTS

We analysed all hospital discharges from all NHS hospitals in Portugal (98,408 hospital discharges corresponding to 57,984 patients). National rates of hospitals episodes for the codes for procedures used were low before anti-VEGF approval in 2007 (less than 12% of hospital discharges). Between 2007 and 2012, the rates of hospital episodes related to the introduction of anti-VEGF injections increased by 27% per year. Patients from areas without ophthalmology departments received fewer treatments than those from areas with ophthalmology departments. The availability of an ophthalmology department in the county increased the rates of hospital episodes by 243%, and a 100-persons greater density per km(2) raised the rates by 11%.

CONCLUSIONS

Our study shows a large but unequal diffusion of anti-VEGF treatments despite the universal coverage and very low copayments. The technological innovation in ophthalmology may thus produce unexpected inequalities related to financial constraints unless the implementation of innovative techniques is planned and regulated.

Enrichment of Bruch's Membrane from Human Donor Eyes

Age-related macular degeneration (AMD) is a leading cause of visual impairment in the developed world. The disease manifests itself by the destruction of the center of the retina, called the macula, resulting in the loss of central vision. Early AMD is characterised by the presence of small, yellowish lesions called soft drusen that can progress onto late AMD such as geographic atrophy (dry AMD) or neovascularisation (wet AMD). Although the clinical changes are well described, and the understanding of genetic influences on conferring AMD risk are getting ever more detailed, one area lacking major progress is an understanding of the biochemical consequences of genetic risk. This is partly due to difficulties in understanding the biochemistry of Bruch’s membrane, a very thin extracellular matrix that acts as a biological filter of material from the blood supply and a scaffold on which the retinal pigment epithelial (RPE) cell monolayer resides. Drusen form within Bruch’s membrane and their presence disrupts nutrient flow to the RPE cells. Only by investigating the protein composition of Bruch’s membrane, and indeed how other proteins interact with it, can researchers hope to unravel the biochemical mechanisms underpinning drusen formation, development of AMD and subsequent vision loss. This paper details methodologies for enriching either whole Bruch’s membrane, or just from the macula region, so that it can be used for downstream biochemical analysis, and provide examples of how this is already changing the understanding of Bruch’s membrane biochemistry.

Combined Nonmydriatic Spectral-Domain Optical Coherence Tomography and Nonmydriatic Fundus Photography for the Detection of Age-Related Macular Degeneration Changes

BACKGROUND AND OBJECTIVE

Nonmydriatic fundus photography (FP) has been a suboptimal tool for detecting age-related macular degeneration (AMD) changes. This study sought to enhance the detection of AMD changes by combining nonmydriatic FP with nonmydriatic spectral-domain optical coherence tomography (SD-OCT).

PATIENTS AND METHODS

The study population included 249 patients aged 65 years and older who were assessed for AMD changes using standard mydriatic biomicroscopic fundus examination. Each eye then underwent nonmydriatic FP in one session followed 1 week later with nonmydriatic FP coupled with nonmydriatic SD-OCT. Images were interpreted for detection of AMD changes, and findings were compared to the original mydriatic biomicroscopic examination.

RESULTS

Nonmydriatic FP had 64% sensitivity, 97% specificity, and a kappa value of 0.67 in detecting AMD changes compared with the traditional mydriatic biomicroscopic examination. Combined nonmydriatic FP and nonmydriatic SD-OCT increased sensitivity to 91.5%, specificity to 98.6%, and kappa to 0.91.

CONCLUSION

The addition of nonmydriatic SD-OCT to nonmydriatic FP enhances the detection of AMD changes.

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

OBJECTIVES

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

DESIGN

Prospective cohort study.

SETTING

Four U.S. clinical centers.

PARTICIPANTS

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

MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

Age-related macular degeneration and the role of the complement system

Age-related macular degeneration (AMD) is a leading cause of visual impairment. It is characterised by damage to a tissue complex composed of the retinal pigment epithelium, Bruch's membrane and choriocapillaris. In early AMD extracellular debris including drusen accumulates in Bruch's membrane and then in late AMD geographic atrophy and/or neovascularisation develop. Variants in genes encoding components of the alternative pathway of the complement cascade have a major influence on AMD risk, especially at the RCA locus on chromosome 1, which contains CFH and the CFHR genes. Immunohistochemical studies have demonstrated complement components in unaffected and AMD macular tissue. Whilst other factors, including oxidative stress, play important roles in AMD pathogenesis, evidence for the central role played by complement dysregulation is discussed in this review.

National Eye Institute Visual Function Questionnaire: usefulness in glaucoma

The National Eye Institute Visual Function Questionnaire 25 (NEI-VFQ-25) is the most commonly used patient-reported outcome measure to assess vision-related quality of life in patients with glaucoma. Glaucoma negatively affects the composite and several NEI-VFQ subscale scores; this effect is correlated with the severity of glaucomatous visual field loss. Contrast sensitivity, glare, and dark adaptation are potential items that could be added to the NEI-VFQ to make it more responsive to changes in vision-related quality of life in patients with glaucoma.

Is age-related macular degeneration a microvascular disease?

Age-related macular degeneration (AMD) is a common, degenerative disease of the central retina affecting millions of elderly in the USA alone and many more worldwide. A better understanding of the pathophysiology of AMD will be essential for developing new treatments. In this review, we discuss the potential impact of complement complex deposition at the choriocapillaris of aging eyes and the relationship between choriocapillaris loss and drusen formation. We further propose a model that integrates genetic and anatomical findings in AMD and suggest the implications of these findings for future therapies.

Pharmacogenetics of the treatment response of age-related macular degeneration with ranibizumab and bevacizumab

INTRODUCTION

Age-related macular degeneration is a major cause of blindness among people aged 50 and older in industrialized countries. Anti-VEGF therapy has been tremendously successful in the treatment of neovascular macular degeneration. Examining the pharmacogenetics of patients' response to the anti-VEGF molecules could allow for a tailored treatment strategy based on patients' underlying genetics rather than the "one-size fits all" approach currently used.

METHODS

Review of the English literature for papers examining the pharmacogenetics of treatment response of neovascular macular degeneration to either ranibizumab or bevacizumab. Polymorphisms in CFH, ARMS2, HTRA1 and VEGF A were examined and reviewed.

RESULTS

Patients with the high-risk CC genotype in complement factor H (CFH) had a worse response to therapy with ranibizumab and bevacizumab. No clear trends were found with ARMS2, HTRA1 and VEGF A.

CONCLUSIONS

The goal of personalized medicine is to craft a treatment program that is ideally suited to an individual patient's disease and genetic make-up rather than simply what works for a large population who share similar disease characteristics. Continued research is needed to achieve this goal for the treatment of age-related macular degeneration.

Projected prevalence of age-related macular degeneration in Scandinavia 2012-2040

PURPOSE

To project the number of persons with late age-related macular degeneration (AMD) in Scandinavia through 2040.

METHODS

Age- and sex-specific prevalence rates of late AMD (choroidal neovascularization and geographic atrophy) from the European Eye Study and the Eye Diseases Prevalence Research Group were applied to the projected Danish, Norwegian and Swedish population from 2012 to 2040.

RESULTS

A total of 187 000 persons aged ≥65 years in Scandinavia are currently affected by late AMD: 47 000 in Denmark, 43 000 in Norway and 97 000 in Sweden. Owing to an ageing population, the number of persons affected by late AMD will increase 75% to 328 000 in 2040.

CONCLUSION

The number of patients with late AMD in Scandinavia is expected to increase substantially over the next three decades, resulting in increased demand for ophthalmic health services.

Medicare costs for neovascular age-related macular degeneration, 1994-2007

PURPOSE

To assess changes in Medicare payments for neovascular age-related macular degeneration (AMD) since introduction of anti-vascular endothelial growth factor (VEGF) therapies.

DESIGN

Retrospective, longitudinal cohort study.

METHODS

Using the Medicare 5% sample, beneficiaries with new diagnoses of neovascular AMD in 1994 (N = 2497), 2000 (N = 3927), and 2006 (N = 6041) were identified using International Classification of Diseases (ICD-9-CM). The total first-year health care and eye care costs were calculated for each beneficiary. Propensity score matching was used to match individuals in the 2000 and 2006 cohorts with the 1994 cohort on age, sex, race, Charlson Comorbidity Index, and low vision/blindness.

RESULTS

The number of beneficiaries newly diagnosed with neovascular AMD more than doubled between the 1994 and 2006 cohorts. Overall yearly Part B payments per beneficiary increased significantly from $3567 for the 1994 to $5991 for the 2006 cohort (P < .01) in constant 2008 dollars. Payments for eye care alone doubled from $1504 for the 1994 cohort to $3263 for the 2006 cohort (P < .01). Most of the increase in payments for eye care in 2006 reflected payments for anti-VEGF injections, which were $1609 over 1 year. Mean annual numbers of visits and imaging studies also increased significantly between the 1994 and 2006 cohort. Results were similar in the matched sample.

CONCLUSIONS

The introduction of anti-VEGF intravitreal injections has offered remarkable clinical benefits for patients with neovascular AMD, but these benefits have come at the cost of an increased financial burden of providing care for these patients.