The dimensions of the problem of eye disease among the elderly

First steps for the development of silk fibroin-based 3D biohybrid retina for age-related macular degeneration (AMD)

Age-related macular degeneration is an incurable chronic neurodegenerative disease, causing progressive loss of the central vision and even blindness. Up-to-date therapeutic approaches can only slow down he progression of the disease.

OBJECTIVE

Feasibility study for a multilayered, silk fibroin-based, 3D biohybrid retina.

APPROACH

Fabrication of silk fibroin-based biofilms; culture of different types of cells: retinal pigment epithelium, retinal neurons, Müller and mesenchymal stem cells ; creation of a layered structure glued with silk fibroin hydrogel.

MAIN RESULTS

In vitro evidence for the feasibility of layered 3D biohybrid retinas; primary culture neurons grow and develop neurites on silk fibroin biofilms, either alone or in presence of other cells cultivated on the same biomaterial; cell organization and cellular phenotypes are maintained in vitro for the seven days of the experiment.

SIGNIFICANCE

3D biohybrid retina can be built using silk silkworm fibroin films and hydrogels to be used in cell replacement therapy for AMD and similar retinal neurodegenerative diseases.

Age-related changes of the human retinal vessels: Possible involvement of lipid peroxidation

BACKGROUND

Aging of the human retina is accompanied by oxidative stress that exerts profound changes in the retinal neurons. It is unknown if oxidative stress influences the cellular components of the retinal vessels in some ways.

METHODS

We examined changes in retinal vessels in human donor eyes (age: 35-94 years; N=18) by light and transmission electron microscopy, TUNEL and immunohistochemistry for biomarkers of vascular smooth muscle cells (SMC; actin), oxidative stress (4-hydroxy 2-nonenal [HNE] and nitrotyrosine), microglia (Iba-1) and vessels (isolectin B₄).

RESULTS

The earliest changes in the endothelium and pericytes of capillaries are apparent from the seventh decade. With aging, there is clear loss of organelles and cytoplasmic filaments, and a progressive thickening of the endothelial and pericyte basal lamina. Loss of filaments, accumulation of lipofuscin and autophagic vacuoles are significant events in aging pericytes and SMC. Actin immunolabelling reveals discontinuity in arterial SMC layers during eighth decade, indicating partial degeneration of SMC. This is followed by hyalinization, with degeneration of the endothelium and SMC in arteries and arterioles of the nerve fibre layer (NFL) and ganglion cell layer in ninth decade. Iba-1 positive microglia were in close contact with the damaged vessels in inner retina, and their cytoplasm was rich in lysosomes. HNE immunoreactivity, but not of nitrotyrosine, was detected in aged vessels from seventh decade onwards, suggesting that lipid peroxidation is a major problem of aged vessels. However, TUNEL positivity seen during this period was limited to few arteries and venules of NFL.

CONCLUSION

This study shows prominent age-related alterations of the pericytes and SMC of retinal vessels. These changes may limit the energy supply to the neurons and be responsible for age-related loss of neurons of the inner retina.

The Royal College of Ophthalmologists' National Ophthalmology Database Study of cataract surgery. Report 5: Clinical outcome and risk factors for posterior capsule rupture and visual acuity loss following cataract surgery in patients aged 90 years and older

BACKGROUND

Older age is commonly associated with an increased risk of surgical complications and comparatively poor outcomes.

PURPOSE

To report cataract surgery outcomes and risk indicators for patients aged 90 years and older.

METHODS

Data collected as part of routine cataract care in 34 centres contributing to the United Kingdom Royal College of Ophthalmologists' National Ophthalmology Database (NOD) were analysed. Very elderly people undergoing cataract surgery were profiled in terms of demographics, pre- and postoperative best-measured visual acuity (VA), ocular co-morbidities, intraoperative posterior capsule rupture (PCR) or vitreous loss or both, and risk indicators for operative PCR and adverse VA outcome.

RESULTS

25,856 cataract operations in 19,166 people of 90 years or older between 2000 and 2014 are reported. Preoperative VA was available for 82.4% eyes, being 0.30 LogMAR or better in 21.5%. Postoperative VA was available for 61.8% eyes, being 0.30 LogMAR or better in 74.4%. For those without ocular co-morbidity, postoperative VA was 0.30 LogMAR or better in 84.7%. Various co-morbidities were present in 49% and contributed to an adverse VA outcome. PCR data were available for all operations and occurred in 2.7%. Significant risk indicators for PCR included pseudoexfoliation/phakodonesis, mature cataract, smaller pupil and worse preoperative VA.

CONCLUSIONS

Slightly poorer cataract surgery outcome results were noted in patients of 90 years or older, more so in patients with ocular co-morbidity which was highly prevalent. However, surgeons should not be deterred from offering cataract surgery to the very elderly as successful visual rehabilitation remains achievable.

Altered Expression Patterns of the Sumoylation Enzymes E1, E2 and E3 Are Associated with Glucose Oxidase- and UVA-Induced Cataractogenesis

PURPOSE

Protein sumoylation is a well established regulatory mechanism that regulates chromatin structure and dynamics, cell proliferation and differentiation, stress response and cell apoptosis. In the vertebrate eye, we and others have shown that sumoylation plays an indispensable role in regulating eye development. During stress induction and aging process, the ocular tissues gradually loss their normality and develop major ocular diseases such as cataract and aging-related macular degeneration. We have recently demonstrated that sumoylation actively regulates differentiation of lens cells, whether this process is implicated in lens pathogenesis remains to be investigated. In this study, we have demonstrated that transparent mouse lenses treated with glucose oxidase and UVA irradiation undergo in vitro cataract formation, and associated with this process, the expression patterns of the 3 sumoylation enzymes have been found significantly altered.

METHODS

Four-week-old C57BL/6J mice were used in our experiment. Lenses were carefully excised from eyes and cultured in M199 medium (Sigma 3769) for at least 12 hours. Transparent lenses (without surgical damage) were selected for experimentation. The lenses were exposed to UVA for 60 min or treated with 30 mU/mL glucose oxidase (GO, MP Biomedicals, 1673) to induce cataract formation. The mRNA levels were analysed with qRT-PCR. The protein levels were determined with western blot analysis and quantitated with Image J.

RESULTS

we have obtained the following results: 1) Both GO treatment and UVA irradiation can induce cataract formation in the in vitro cultured mouse lenses; 2) With GO treatment, the mRNAs and proteins for the 5 sumoylation enzymes were all significantly downregulated; 3) With UVA irradiation, the changes in the expression patterns of the mRNAs and proteins for the SAE1, UBA2 , UBC9 and PIAS1 were opposite, while the mRNAs were upregulated either significantly (for SAE1, UBA2 and UBC9) or slightly (PIAS1), the proteins for all 4 sumoylation enzymes were downregulated; For RanBP2, the UVA induced changes in both mRNA and protein are consist with the GO treatment.

CONCLUSION

Under GO and UVA irradiation conditions, the expression levels of both mRNA and protein for the three major sumoylation enzymes were significantly changed. Our results suggest that altered expression patterns of the sumoylation enzymes are associated with oxidative stressinduced cataractogenesis.

PREDICTIVE FACTORS FOR DEVELOPMENT OF NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: A Spectral-Domain Optical Coherence Tomography Study

PURPOSE

To investigate the risk factors predictive for the development of neovascular age-related macular degeneration (NVAMD) by means of spectral-domain optical coherence tomography.

METHODS

Retrospective study of 73 eyes graded Stage 2 and Stage 3 according to the AMD International Grading System with minimum follow-up of 24 months. Drusenoid pigment epithelial detachment, hyperreflective foci, external limiting membrane, inner ellipsoid band, and retinal pigment epithelium integrity were analyzed at baseline and last follow-up. Binary logistic regression model analyzed significant predictors of neovascular conversion.

RESULTS

The discontinuity of external limiting membrane, inner ellipsoid band, and retinal pigment epithelium bands were significantly more prevalent in the NVAMD group at baseline and last follow-up (P < 0.001). Hyperreflective foci represented the single most important predictor of neovascular conversion (Exp [B], 15.15; P = 0.005) as confirmed by Kaplan-Meier curve (P = 0.002). Drusenoid pigment epithelial detachment width was significantly greater in NVAMD group than control subjects at baseline and last follow-up (P < 0.001), and its delta value also resulted a significant neovascular predictor (Exp [B], 0.99; P = 0.04).

CONCLUSION

Hyperreflective foci significantly increase the risk of NVAMD progression. The delta width of drusenoid pigment epithelial detachment also predicts disease progression, integrating the stratification of NVAMD progression risk.

Verteporfin Therapy and Triamcinolone Acetonide: Convergent Modes of Action for Treatment of Neovascular Age-Related Macular Degeneration

PURPOSE

Choroidal neovascularization associated with age-related macular degeneration is the primary cause of blindness in the elderly in developed countries, due to a number of pathogenic effects, including angiogenesis, cell-mediated inflammation, leukocyte adhesion and extravasation, and matrix remodeling.

METHODS

By producing photochemical effects at the site of target tissue (lesion), photodynamic therapy (PDT) can induce vascular damage and blood flow stasis, leading to occlusion of vascularization and lesion leakage.

RESULTS

PDT with verteporfin (Visudyne, Novartis) has been shown to be safe and effective in reducing the risk of vision loss in patients with classic containing subfoveal CNV and occult with no classic CNV. However, in predominantly occult CNV, the treatment may be most effective in smaller lesions, and less in larger lesions. Most important, visual acuity rarely is improved.

CONCLUSIONS

Pilot studies and large case series suggest that a combination of PDT and intravitreal triamcinolone acetonide has the potential to improve visual outcomes and reduce the need for additional treatments. Randomized, prospective clinical trials are underway to confirm the efficacy and safety of this novel treatment modality.

Health literacy of common ocular diseases in Nepal

BACKGROUND

Poor health literacy is often a key cause of lack of or delayed uptake of health care services. The aim of this study was to assess the health literacy of common ocular diseases, namely cataract, glaucoma, night blindness, trachoma and diabetic retinopathy in Nepal.

METHODS

A cross sectional study of 1741 participants randomly selected from non-triaged attendants in the outpatient queue at Tilganga Institute of Ophthalmology, a semi urban general population of Bhaktapur district of Kathmandu Valley and patients attending rural outreach clinics. Participants responded to trained enumerators using verbally administered, semi structured questionnaires on their awareness and knowledge of cataract, glaucoma, diabetic retinopathy, night blindness, and trachoma.

RESULTS

The awareness of cataract across the entire sample was 49.6%, night blindness was 48.3%, diabetic retinopathy was 29%, glaucoma was 21.3% and trachoma was 6.1%. Patients presenting to rural outreach clinics had poorer awareness of cataract, glaucoma, diabetic retinopathy, night blindness and trachoma compared to those from a semi-urban community and an urban eye hospital (p<0.05), Old age was directly associated with poorer awareness of cataract, glaucoma, night blindness, trachoma and diabetic retinopathy (p<0.05). Female gender was associated with lower awareness of cataract, glaucoma, night blindness and trachoma (p<0.05). Literacy was associated with greater awareness of cataract, glaucoma, diabetic retinopathy, night blindness and trachoma (p<0.05). Higher education was significantly associated with greater awareness of cataract, night blindness and trachoma (p<0.05). Multivariate analysis found that the awareness of common ocular diseases was significantly associated with level of education (p<0.05). Similarly, awareness of cataract, glaucoma, trachoma and night blindness was associated with female gender (p<0.05) whereas awareness of cataract, night blindness, trachoma and diabetic retinopathy was associated with age (p<0.05) but the awareness glaucoma and diabetic retinopathy was associated with camps.

CONCLUSIONS

Low awareness of common ocular conditions is associated with factors such as female gender, old age, lower levels of education and rural habitation. A would be successful health promotion programs should specifically target health determinants to promote health literacy and to ensure timely utilization of eye care services.

Feasibility of telemedicine in detecting diabetic retinopathy and age-related macular degeneration

Age-related macular degeneration and diabetic retinopathy are important causes of visual impairment and blindness in the world. Because of recent advances and newly available treatment modalities along with the devastating consequences associated with late stages of these diseases, much attention has been paid to the importance of early detection and improving patient access to specialist care. Telemedicine or, more specifically, digital retinal imaging utilizing telemedical technology has been proposed as an important alternative screening and management strategy to help meet this demand. In this paper, we perform a literature review and analysis that evaluates the validity and feasibility of telemedicine in detecting diabetic retinopathy and age-related macular degeneration. Understanding both the progress and barriers to progress that have been demonstrated in these two areas is important for future telemedicine research projects and innovations in telemedicine technology.

Pilot study for the detection of early exudative age-related macular degeneration with optical coherence tomography

BACKGROUND

Optical coherence tomography (OCT) provides microscopic retinal images. Optical coherence tomography is noninvasive, using light waves to produce detailed retinal images. Here, we investigate the ability of OCT to detect early choroidal neovascularization in age-related macular degeneration.

METHODS

Seventy-nine patients, diagnosed with nonexudative macular degeneration in one eye and exudative macular degeneration in the other were enrolled in this prospective, observational, nonrandomized study. Participants underwent examination (visual acuity, intraocular pressure, biomicroscopy, and ophthalmoscopy) followed by OCT in the study eye (nonexudative macular degeneration eye) every 3 months for 2 years. If examination did not show choroidal neovascularization, but OCT images raised suspicion, patients were reexamined in 4 weeks to 6 weeks and/or fluorescein angiography was performed. Visual acuity, OCT anomaly detected, and time between OCT and fluorescein angiography detection were examined.

RESULTS

Fifteen (19%) patients developed exudative macular degeneration, as confirmed by fluorescein angiography, in the study eye. Four additional patients showed potential exudative macular degeneration on OCT only. Of the 15 patients who developed exudative macular degeneration, 13 had disease progression identified on OCT before examination and/or fluorescein angiography showed changes. Subretinal pigment epithelium fluid was the most common OCT anomaly, with development of sub-/intraretinal fluid also visible.

CONCLUSION

Optical coherence tomography could be a powerful screening tool for patients with age-related macular degeneration at high risk for developing choroidal neovascularization.

Cost effectiveness of treatments for wet age-related macular degeneration

Age-related macular degeneration (AMD) is a leading cause of blindness in people aged ≥50 years. Wet AMD in particular has a major impact on patient quality of life and imposes substantial burdens on healthcare systems. This systematic review examined the cost-effectiveness data for current therapeutic options for wet AMD. PubMed and EMBASE databases were searched for all articles reporting original cost-effectiveness analyses of wet AMD treatments. The Centre for Reviews and Dissemination and Cochrane Library databases were searched for all wet AMD health technology assessments (HTAs). Overall, 44 publications were evaluated in full and included in this review. A broad range of cost-effectiveness analyses were identified for the most commonly used therapies for wet AMD (pegaptanib, ranibizumab and photodynamic therapy [PDT] with verteporfin). Three studies evaluated the cost effectiveness of bevacizumab in wet AMD. A small number of analyses of other treatments, such as laser photocoagulation and antioxidant vitamins, were also found. Ranibizumab was consistently shown to be cost effective for wet AMD in comparison with all the approved wet AMD therapies (four of the five studies identified showed ranibizumab was cost effective vs usual care, PDT or pegaptanib); however, there was considerable variation in the methodology for cost-effectiveness modelling between studies. Findings from the HTAs supported those from the PubMed and EMBASE searches; of the seven HTAs that included ranibizumab, six (including HTAs for Australia, Canada and the UK) concluded that ranibizumab was cost effective for the treatment of wet AMD; most compared ranibizumab with PDT and/or pegaptanib. By contrast, HTAs at best generally recommended pegaptanib or PDT for restricted use in subsets of patients with wet AMD. In the literature analyses, pegaptanib was found to be cost effective versus usual/best supportive care (including PDT) or no treatment in one of five studies; the other four studies found pegaptanib was of borderline cost effectiveness depending on the stage of disease and time horizon. PDT was shown to be cost effective versus usual/best supportive care or no treatment in five of nine studies; two studies showed that PDT was of borderline cost effectiveness depending on baseline visual acuity, and two showed that PDT was not cost effective. We identified no robust studies that properly evaluated the cost effectiveness of bevacizumab in wet AMD.

[Blindness in Germany--today and in 2030]

Due to demographic developments in Germany, it is inevitable that the number of age-related diseases will grow. The aim of this survey is to forecast the extent of this development in ophthalmology. How many people will be blind or visually impaired in 25 years from now? According to the German Federation of Blind and Visually Impaired People, the number of blind people in Germany is about 145,000 and the number of the partially sighted people can be estimated at approximately 500,000. These figures are based on the legal definitions of blindness and visual impairment, which are stricter in Germany than in other countries. Due to the ageing population, there will be one third more blind people and about 60% more new cases of blindness in 25 years time. In particular, the incidence rate of blindness due to age-related macular degeneration will rise sharply, but the number of blind people and new cases of blindness are only the top of the "iceberg". The number of people suffering from age related eye diseases in future will be even larger. This large number of future patients already should be part of health economic considerations.

Innovations in eye surgery

The field of ophthalmology has undergone revolutionary changes during the past few decades. Advancements in understanding the pathophysiology of eye diseases, superior surgical instrumentation and surgeon skills, and cotreatment with medical therapies have enhanced outcomes. The geriatric population, preferentially affected by these illnesses, has seen a meaningful visual benefit from these surgical innovations. Most importantly, these improvements have led to increases in quality-of-life measures and mental and physical well-being of aging patients.

Results of a multicenter clinical trial to evaluate the preferential hyperacuity perimeter for detection of age-related macular degeneration

PURPOSE

To compare the preferential hyperacuity perimeter (PHP) with an Amsler grid in detection of age-related macular degeneration (AMD).

METHODS

Patients underwent refraction, visual acuity examination, PHP, Amsler grid examination, and macular photography.

RESULTS

One hundred fifty patients participated in the trial. Of 19 eyes with neovascular AMD, 19 (100%) were positive on the PHP, and 10 (53%), on the Amsler grid. Of 27 eyes with geographic atrophy, 26 (96%) were positive on the PHP, and 12 (44%), on the Amsler grid. Of 20 eyes with intermediate AMD, 14 (70%) were positive on the PHP, and 4 (20%), on the Amsler grid. Of 51 eyes with early AMD, 21 (41%) were positive on the PHP, and 4 (8%), on the Amsler grid. Of 33 eyes with no AMD, 6 (18%) were positive on the PHP, and none, on the Amsler grid. Thus, 80 (68%) of 117 patients with AMD had a positive PHP, while 30 (26%) had positive results of Amsler grid examination (P < 0.001, McNemar test).

CONCLUSION

The PHP had greater sensitivity, although with a relatively high rate of false-positive results for healthy individuals, than the Amsler grid in detecting AMD-related lesions.

The prevalence of eye disease in nursing home and non-nursing home geriatric populations

The objective of this study was to determine whether rates of eye disease among the elderly are higher for residents of nursing homes than for persons who reside elsewhere. Articles reporting the prevalence of eye disease in geriatric populations (classified as nursing home or non-nursing home) were identified through a Medline search and a search of articles' bibliographies. Identified articles were reviewed, and the relevant data compared with prevalence rates obtained from 738 residents of two nursing homes in New York City. Each of the nursing home residents received an ocular examination upon admission that determined the presence or absence of four varieties of eye disease-i.e. cataracts, age-related macular degeneration, glaucoma, and diabetic retinopathy. Demographic data were obtained through chart review. Results indicate that prevalence rates of eye disease found in geriatric nursing home populations are generally higher than those found in other geriatric populations. With the exception of the rates for diabetic retinopathy, the rates found in the combined nursing home population sampled in this study were much higher than those reported in any previous study. It is concluded that eye disease is a more serious problem for elderly residents of nursing homes than for the elderly who reside in the community. Possible reasons for this are discussed.

Prospective evaluation of digital non-stereo color fundus photography as a screening tool in age-related macular degeneration

PURPOSE

To evaluate mydriatic, non-stereo digital color fundus photographs as a screening tool for identifying and classifying exudative age-related macular degeneration (AMD).

DESIGN

Prospective case series.

METHODS

Digital color fundus photographs were obtained from patients seen in the AMD screening clinic over a 9-month period at the Ivey Eye Institute in London, Ontario. Photographs for eligible patients were separated by eye, cataloged, blinded, and randomly labeled before interpretation by an experienced vitreoretinal surgeon. Exact agreement, sensitivity, specificity, positive predictive value, and negative predictive value of the fundus photographs in diagnosing, classifying, and managing cases of suspected exudative AMD were then calculated against gold standard clinical examination and fluorescein angiography.

RESULTS

A total of 223 images were used from 118 eligible patients. Exact agreement between photographic evaluation and gold standard ranged from 89.2% (presence of pigment epithelial detachment (PED)) to 82.5% (evidence of retinal pigment epithelium geographic atrophy). Sensitivities ranged from 89.2% (presence of choroidal neovascular membrane (CNVM)) to 40.0% (presence of PED). Specificities ranged from 94.1% (presence of PED) to 86.8% (presence of retinal pigment epithelium geographic atrophy). Positive predictive value ranged from 86.1% (presence of CNVM) to 40.0% (presence of PED). Negative predictive value ranged from 94.1% (presence of PED) to 88.9% (presence of CNVM). As a screening tool for high-risk dry changes and active exudative changes, overall sensitivity specificity, positive predictive value, and negative predictive value were 82.1%, 79.1%, 70.4%, and 88.0%, respectively.

CONCLUSIONS

Digital, non-stereo color fundus photographs are highly sensitive and have high negative predictive value as a screening tool. Very few treatable lesions are missed using telemedicine in age-related macular degeneration.

Clinical outcome following cataract surgery in very elderly patients

PURPOSE

The number of very elderly patients waiting for cataract surgery is predicted to increase. The aim of our study was to determine the clinical outcome following cataract surgery in this age group.

METHODS

In this retrospective study, patients aged 96 years and above, who underwent cataract surgery between June 1993 and January 2001, were identified. Clinical data were retrieved from their medical records. Living patients were further invited for clinical examination.

RESULTS

In all, 34 eyes of 21 patients (20 females) were identified. Six patients were deceased. In total, 30/34 eyes had phacoemulsification and four had extracapsular extraction. Preoperative vision was <or=6/36 in 24/34 eyes (70.59%) and <or=CF in 16/34 eyes (47.06%). Postoperative vision was >or=6/60 in 25/34 eyes (73.53%), >or=6/18 in 21/34 eyes (61.76%), and >or=6/9 in 10/34 eyes (29.41%). Visual acuity improved in 24/34 eyes (70.59%) and remained the same in 6/34 eyes. Complications included anterior capsule tear (three), zonular dialysis with vitreous loss (one), posterior capsule rupture with vitreous loss (one), incarceration of iris to paracentesis wound (two), postoperative uveitis (two), and posterior capsular opacification (19). In all, 7/34 eyes had undergone YAG capsulotomy.

CONCLUSION

Surgeons should not be deterred from offering cataract surgery to the very elderly as successful visual rehabilitation is the norm. A further prospective multicentre study is required to confirm the benefits and assess the risks of cataract surgery in this age group.

Current concepts and recent advances in the management of age-related macular degeneration

BACKGROUND

Age-related macular degeneration (AMD) is the leading cause of visual impairment and blindness in the Western World in those aged 65 and older. At present, several treatment modalities are utilised and several more are undergoing investigation in an attempt to retard the occurrence and progression of this devastating condition.

AIMS

To provide the non-ophthalmologist with an understanding of the current treatment options available to patients suffering from all variants of AMD.

METHODS

Medline and Embase search.

RESULTS

Several treatment modalities have been investigated and utilised in the treatment of all variants of this condition. While promising results have been reported, no treatment is ideal.

CONCLUSION

While no curative treatment for this condition currently exists, early recognition and treatment, if indicated, have been shown to reduce the risk of severe vision loss in patients with this condition.

Replacing the Amsler grid: a new method for monitoring patients with age-related macular degeneration

PURPOSE

To investigate a method that uses hyperacuity, the Macular Computerized Psychophysical Test (MCPT), to evaluate the central macular visual field in patients with age-related macular degeneration (AMD).

DESIGN

Prospective case-control study of a diagnostic test.

PARTICIPANTS AND CONTROLS

One hundred eight eyes of 108 Patients with AMD and 51 eyes of 51 age-matched patients with no retinal disease. Patients with AMD included 32 (30%) patients with choroidal neovascularization (CNV), 23 (21%) with geographic atrophy (GA), 35 (32%) with AMD with high-risk characteristics (HRC), and 18 (17%) with early AMD with non-HRC.

TESTING

Each subject underwent the MCPT, in which a virtual line composed of dots (white dots on a black background, maximal contrast) is flashed across different macular loci to a perifoveal radius of 7 degrees. Patients' responses were recorded and automatically analyzed using a specific algorithm developed before the onset of the study. All patients also underwent a supervised Amsler grid examination on the encounter before or after the MCPT in random order.

MAIN OUTCOME MEASURES

Distortion, scotoma, or blurring perceived by the patient after a swift change of fixation was considered positive on the MCPT. Any perception of distortion, scotoma, or blurring was considered positive on the Amsler grid.

RESULTS

Of the 32 patients with CNV, 30 (94%) were found positive on the MCPT and 11 (34%) were found positive on the Amsler grid. Of the 23 GA patients, 21 (91%) were found positive on the MCPT and 7 (30%) were found positive on the Amsler grid. Of the 35 HRC patients, 28 (80%) were found positive on the MCPT and 3 (9%) were found positive on the Amsler grid, and of the 18 early AMD with non-HRC patients, 8 (44%) were found positive on the MCPT and 3 (17%) were found positive on the Amsler grid. Of the 51 controls, 3 (6%) were positive on the MCPT and 1 (2%) was positive on the Amsler grid.

CONCLUSIONS

The MCPT was superior to the Amsler grid in detecting AMD-related lesions in this cohort. Studies are underway to determine whether the MCPT is feasible for home monitoring to provide early detection of progression to CNV.

Sleep Complaints and Visual Impairment Among Older Americans: A Community-Based Study

BACKGROUND

This report describes the associations between sleep complaints and reported visual impairment in an urban community-residing older adult sample.

METHODS

A total of 1118 volunteers from a biracial cohort participated in the study (mean age = 74 +/- 6; mean body mass index = 28 +/- 10). Volunteers were recruited using a stratified, cluster sampling technique. In a standard order, several questionnaires were administered, soliciting information on socioeconomic status, physical health, social support, and emotional experience. The physical health questionnaire included questions on whether or not the volunteer experienced sleep disorder, visual impairment, heart disease, respiratory disease, arthritis, and hypertension. In this report, we present data on the prevalence of reported sleep problems and visual impairment among older adults.

RESULTS

Of the total sample, 9% used sleep medicine, 25% reported difficulty falling asleep, 52% indicated experiencing difficulty maintaining sleep, 28% reported waking up early in the morning, and 12% reported daytime sleep longer than 2 hours. Chi-square results showed greater sleep complaints for volunteers with visual impairment. Consistent with these results, analysis of variance revealed that visually impaired volunteers had a higher index rate of sleep disturbance (F((1, 1110)) = 35.32, p <.0001).

CONCLUSIONS

These data provide evidence that older adults reporting visual impairment are also likely to report sleep complaints. This verifies laboratory findings of an association of ophthalmic diseases with sleep-wake problems and with circadian rhythm abnormalities.

A prospective study of alcohol consumption and the risk of age-related macular degeneration

PURPOSE

Vascular risk factors, including alcohol intake, have been hypothesized to play a role in the development of age-related macular degeneration (AMD). We examined the relationship of alcohol intake with AMD in the Physicians' Health Study (PHS).

METHODS

The PHS was a randomized trial of aspirin and beta-carotene among 22,071 U.S. male physicians age 40 to 84 years at entry. A total of 21,041 physicians with complete data on alcohol consumption and no AMD at baseline were included in this analysis. Proportional hazards models were used to estimate relative risks (RR) and 95% confidence interval (CI).

RESULTS

During an average follow-up period of 12.5 years, 278 physicians were confirmed by medical record review to have incident AMD resulting in vision loss ( acuity 20/30 or worse). After adjusting for age, randomized treatment assignment, and other potential risk factors, the RR for > or = 1 drink/week versus < 1 drink/week was 0.97 (CI: 0.78-1.21). For categories of alcohol intake, the RRs for those reporting alcohol consumption of < 1 drink/week, 1 drink/week, 2-4 drinks/week, 5-6 drinks/week, and > or = 1 drink/day were 1.00 (referent), 1.00 (0.65-1.55), 0.68 (0.44-1.04), 1.32 (0.89-1.95), and 1.27 (0.93-1.73), respectively.

CONCLUSIONS

These prospective data indicate that alcohol intake is not appreciably associated with the risk of incident AMD. However, the width of the confidence intervals are compatible with a possible small effect (reduction or increase) in risk for low to moderate levels of alcohol intake, which warrant further investigation.

Cloning, high level-expression and characterization of human lens thioltransferase

Polymerase chain reaction (PCR) primers, directed against the nucleotide sequence of pig liver thioltransferase (PLTT) were used to amplify human lens thioltransferase (HLTT) from a pool of human lens cDNA. The 520 bp PCR fragment obtained was cloned unidirectionally into pCR 3.1-Uni vector and sequenced. The cDNA sequence of the lens thioltransferase had 98% and 87% homology to pig liver and human placental thioltransferases (TTase) respectively. Nhe1 and EcoR1 fragment of the recombinant PCR 3.1-Uni vector was subcloned in pET 23a Expression vector. High level expression of HLTT was accomplished in Escherichia coli and the expressed protein was characterized by immunoblot analysis with anti PLTT and N-terminal amino acid sequence analysis. The recombinant enzyme efficiently dethiolated protein thiol mixed disulfides conjugated to both cystine (PSSC) and glutathione (PSSG) and had a significant dehydroascorbate reductase activity. Human lens thioltransferase thus displayed structural and functional characteristics identical to pig liver and human placental thioltransferases.

Moderate wine consumption is associated with decreased odds of developing age-related macular degeneration in NHANES-1

OBJECTIVE

To determine the association between alcohol intake and the risk of developing age-related macular degeneration (AMD).

DESIGN

Case control study.

PARTICIPANTS

The sample consisted of 3072 adults 45 to 74 years of age with macular changes indicative of AMD who participated in a nationally representative sample of the first National Health Nutrition and Examination Survey (NHANES-1) between 1971 and 1975: (a) the ophthalmology data set and (b) the medical history questionnaire.

MAIN OUTCOME MEASURES

Alcohol intake and the risk of developing AMD were measured. AMD was determined by staff at the National Eye Institute by fundoscopy examination using standardized protocol.

RESULTS

Overall, 184 individuals (6%) had AMD. We observed a statistically significant but negative association between AMD and the type of alcohol consumed in a bivariate model (OR 0.86; 95% CI 0.73, 0.99). In the same model, age maintained a consistently strong association with AMD (OR 1.08; 95% CI 1.06-1.11; P < .001). Among the different types of alcohol consumed in NHANES-1 (beer, wine, and liquor), the effect of wine, either alone (OR 0.66; 95% CI 0.55-0.79) or in combination with beer (OR 0.66; 95% CI 0.55-0.79) or liquor (OR 0.74; 95% CI 0.63-0.86), dominated the negative association observed between AMD and alcohol type. Additionally, a statistically significant and negative association between wine and AMD was noted after adjusting for the effect of age, gender, income, history of congestive heart failure, and hypertension (OR 0.81; 95% CI 0.67-0.99).

CONCLUSION

Moderate wine consumption is associated with decreased odds of developing AMD. Health promotion and disease prevention activities directed at cardiovascular disease may help reduce the rate of AMD-associated blindness among older people. The nature and pathophysiology of this association warrant further investigation.

A telephone survey of day-surgery eye patients

The objective of this research study was to evaluate the nursing care processes and patient satisfaction with the new day-surgery services. Forty-five adult day-surgery eye patients were selected at random to take part in a telephone survey. The response rate was 84.4% (38). Patients were contacted 48 hours post-surgery to obtain their view of the entire surgical experience. The research result found that the majority of the patients were satisfied with the day-surgery services. The main problems experienced by patients were long waiting times to see the doctor during pre-operation assessment, unsatisfactory journeys to and from theatre, and difficulty in remembering verbal advice. Twenty-eight (73.6%) of the day-surgery patients would prefer day-surgery again for a similar operation, but 10 (26.3%) would prefer a longer stay in hospital. The main implications for practice are that realistic assessment time should be allocated to reduce waiting time, verbal advice should be accompanied by written leaflets or audio-tape, and patients should be encouraged to make an informed choice about day or in-patient surgery. A regular survey of day-surgery eye patients should be part of a general audit.

Cataract and latitude

For many years, it has been suggested that exposure to sunlight, particularly its ultraviolet component, may be associated with an increased risk of senile cataract. This paper addresses 1) the physical and geographic variables that affect the entry of ultraviolet light in the eye; 2) the epidemiologic evidence that associates cataract with ultraviolet light exposure; and 3) the effectiveness of personal barrier protection (i.e. sunglasses and hats) in reducing ocular exposure to ultraviolet light. The epidemiologic evidence is drawn from studies in Australia, China, Tibet, and the United States. The U.S. evidence consists of data from the Maryland Watermen study and analyses of cataract surgery under the Medicare program which provides health insurance for nearly all Americans age 65 and over (30 million) and pays for 85% of the 1.3 million cataract extractions performed annually in the U.S. Analysis of the Medicard data shown that, after controlling for age, sex, and race, and income of the population and also controlling for supply of ophthalmologists, optometrists, price of surgery and local practice costs, the strongest predictor of cataract surgery likelihood in a Medicare beneficiary is the person's latitude of residence. Latitude correlates directly with the UV-B content of sunlight, because the incident angle of the sun determines the atmospheric penetration of ultraviolet radiation. Data suggest that the probability of cataract surgery in the U.S. increases by 3% for each 1 degree decrease (i.e. more Southerly) in latitude.

The role of light scatter in the degradation of visual performance before and after Nd:YAG capsulotomy

The aim of this study was to determine whether capsulotomy size influences visual performance. Snellen visual acuity and forward light scatter (light scattered towards the patient's retina, but out of the focussed retinal image) measurements using simple computer graphics based on van den Berg's technique were used to measure visual performance. Twelve patients were studied: 4 had small central capsulotomies through undilated pupils and 8 had wide capsulotomies through dilated pupils. The two groups were matched for age and pre-laser Snellen acuity. Following treatment, both groups had equal improvements in Snellen acuity. There was only a significant (p < 0.001) improvement in forward light scatter readings in the group who received wide capsulotomies. Measurements of forward light scatter are more sensitive than Snellen acuity testing in demonstrating loss of visual performance in patients with media opacities. It is recommended that pupils are dilated prior to Nd:YAG capsulotomy if forward light scatter from capsule remnants and the consequent glare disability are to be minimised.

Is genetic predisposition an important risk factor in age-related macular degeneration?

Age-related macular degeneration (ARMD) is the most common cause of visual morbidity in the aged in the Western world. The aetiology of ARMD is unknown. Although clinicians have noted that ARMD demonstrates a familial tendency, the question regarding the role of hereditary factors in ARMD remains unanswered. The aims of this study were to assess the level of genetic input into ARMD and to assess the mode of inheritance of the disease. Fifty affected patients and 50 age- and sex-matched controls and their immediate families were invited to take part in the study. Thirty-six patients, controls and their families were studied. Eighty-one siblings of affected patients and 78 control siblings were available. Twenty of the 81 affected siblings were found to suffer from ARMD. In contrast only 1 of 78 control siblings had ARMD. This was statistically significant. The results confirm that hereditary factors are important in the aetiology of ARMD.

Eye disease among ambulatory Jewish senior citizens in California

Knowledge of the epidemiology of eye disease among the elderly becomes increasingly important as our population ages. Leading causes of blindness in the elderly include age-related macular degeneration, open-angle glaucoma and cataract. Few studies have examined the prevalence of these blinding eye diseases among senior citizens. A retrospective review of vision screening examinations from 429 patients seen at the UCLA Mobile Eye Clinic in visits to a Jewish senior citizens' center was performed to examine the distribution of best recorded visual acuity and prevalence of eye disease in a group of ambulatory Jewish senior citizens. Best recorded visual acuity was > or = 20/40 in the better eye for 83.9% of the patients. The prevalence of age-related macular degeneration was 20.7%, and increased with increasing age (p < .00005). The prevalence of open-angle glaucoma was 6.3%. The prevalence of senile cataract was 59.0% and increased with increasing age (p < .00005). Despite the limitations imposed by a retrospective review of charts, our study provides an indication of the prevalence of blinding eye disease and distribution of visual acuity among ambulatory Jewish senior citizens in southern California. Except for the high prevalence of senile cataract, the prevalence data derived from this study are similar to other epidemiologic studies of eye disease in the elderly.

Driving competence in older persons

Older drivers form a growing segment of the driving population which in comparison to most other modes of transportation, is relatively user-friendly for older people. There are two important problems. The first is the increase of physical vulnerability with age which means that the same accident often leads to much more severe injury in an older than a younger adult driver. The second problem is the decline of sensory, perceptual-motor and cognitive abilities (impairments) because of ageing-related degenerative processes and diseases. As a result, processing of and responding to traffic information is slowed and activities cannot well be performed simultaneously. Much of this may be compensated by behavioural changes. However, studies of accident characteristics and driving skill in relation to ageing suggest that compensation breaks down in complex and ambiguous traffic situations and in individuals with strongly impaired perceptual and cognitive function. Possible changes to reduce ageing-related accidents, and which make driving more user-friendly for older drivers, are discussed.

Effect of visual impairment on neuropsychological test performance

Three vision-dependent neuropsychological tests of visual processing--Benton's Facial Recognition (FR), Judgment of Line Orientation (JLO), and Visual Form Discrimination (VFD)--were administered to subjects on the same day as routine ophthalmic examination. Seventeen subjects had Jaeger near vision of J5 (analogous to 20/50) or worse resulting from refractive error, while 13 control subjects had normal near vision of J1. Neuropsychological test scores of these groups were compared with each other and also the published standardization group for each test. Low near-vision subjects' performances on FR and VFD were significantly poorer than both control group subjects and standardization group subjects, but performance on JLO was not significantly altered. These results demonstrate that visual impairment can result in unexpectedly low scores on certain tests of visual processing, which suggests that poor vision might also affect results of other neuropsychological tests that involve vision, such as tests of visual processing and tests which use vision as a vehicle to deliver test stimuli to the relevant portions of the cortex. We therefore strongly urge examiners to secure control over potential bias resulting from reduced vision by instituting routine near visual acuity testing of all subjects prior to or during neuropsychological assessment.

Prevalence of eye disorders among the elderly in Los Angeles

A series of 431 vision screening records of seniors 55 years of age and older were analysed. Patients were examined by the UCLA Mobile Eye Clinic at two senior centers in the Los Angeles area, between the years 1982 and 1990. Sixty-eight percent of patients were females and 32% were males. The mean (+/-S.D.) age was 69 (+/-7.5) years. Common diagnoses were refractive errors (65.2%) and impaired visual acuity (37.0%). The prevalences of refractive errors were: hyperopia, 24.8%; myopia, 10.4%; presbyopia, 54.1%; and astigmatism, 31.8%. In most patients (94.0%), impaired visual acuity was corrected by spectacles. The prevalence of cataract was 29.5% and age-specific prevalences of cataract increased with age. The prevalences of other eye disorders were as follows: glaucoma, 6.3%; diabetic retinopathy, 1.2%; and macular degeneration, 5.1%. This study highlights the degree of ophthalmic disorders identified by vision screenings in the elderly population in senior centers; our results are consistent with previously reported studies of eye diseases in the elderly.

Visual impairment among older people

Visual impairment is the most age-related disability, with older people forming the majority of the visually disabled population. This article re-examines the nature of visual impairment among older people and points to a key role for nurses in identification and intervention.

The National Cataract Surgery Survey: I. Method and descriptive features

The National Cataract Surgery Survey is a prospective cross-sectional survey of surgery for age-related cataract within the National Health Service. It is the first national study of cataract surgery in the United Kingdom providing clinical data. This is the first in a series of papers and describes a profile of the characteristics of patients admitted for cataract surgery that includes: demography, referral sources, presence of co-existing ocular pathology, level of visual impairment on admission and waiting time for surgery. A profile of the process of the surgical procedure for 1990 is also described: number of operations performed, type of admission, type of anaesthetic, cataract extraction and intraocular lens and the grade of surgeon performing the procedure.

The increasing frequency of surgery for cataract

The increasing frequency of cataract operation was investigated by examining the age related cataract extraction rates for Glasgow. Detailed analysis of case records of sample patients over the past decade was carried out to characterise trends in frequency of intraocular lens implantation, age of the patient at operation, preoperative visual acuity and rate of operation on the second eye. Between 1980 and 1987 the rate of cataract operation per thousand increased from 7.1 to 10.5 for patients aged 75 years and over and from 3.6 to 4.2 for those aged 65 to 74 years. There was a marked rise in the number of cataract operations relative to other eye operations between 1977 and 1988, from 19.3% to 37% and this increase was greatest in patients of 70 years and over. The same decade has seen intraocular lens implantation rise from 0% to 94.6% of cataract extractions. Visual acuity data show a significant trend towards operation at a better level of acuity in patients aged 70 years and over (p = 0.028) but not in younger age groups. There was no change in the visual acuity of the fellow eyes and no change in the frequency of operation on the second eye. It appears that cataract surgery is increasing more than can be predicted from the age of the population and this must be recognised in planning the future level of ophthalmology services.

Eye disease in a geriatric nursing home population

All 225 tenants (181 female and 44 male patients) of a nursing home in New York City underwent eye examinations at least once within a 1-year period to determine the prevalence of senile cataract, age-related macular degeneration (AMD), open-angle glaucoma, and diabetic retinopathy. The average age was 85.4 years (range, 60-108 years). With aphakia and pseudophakia included in the diagnosis of "cataract," the respective prevalences were found to be 81, 37, 11, and 2.1%. There was a statistically significant increase in the prevalence of cataracts and AMD in those patients 85 years of age or older when compared with the younger patients in the nursing home (P less than 0.05). Of those patients without organic brain syndrome, 44% (66/151) had a visual acuity of 20/40 or better in at least one eye. Thirty percent (45/151) had a visual acuity of 20/200 or worse in both eyes. Although this study has no control population of patients outside nursing homes, a review of the literature suggests that geriatric nursing home patients may have a higher prevalence of eye disease than their chronologic peers outside nursing homes. Further study is necessary to determine whether residents of geriatric nursing homes are receiving adequate ophthalmic care.