Optometry Australia's chairside reference for the diagnosis and management of age-related macular degeneration

ChatGPT-4 for addressing patient-centred frequently asked questions in age-related macular degeneration clinical practice

PURPOSE

Large language models have shown promise in answering questions related to medical conditions. This study evaluated the responses of ChatGPT-4 in answering patient-centred frequently asked questions (FAQs) relevant in age-related macular degeneration (AMD).

METHODS

Ten experts across a range of clinical, education and research practices in optometry and ophthalmology. Over 200 patient-centric FAQs from authoritative professional society, hospital and advocacy websites were condensed into 37 questions across four themes: definition, causes and risk factors, symptoms and detection, and treatment and follow-up. The questions were individually input into ChatGPT-4 to generate responses. The responses were graded by the experts individually using a 5-point Likert scale (1 = strongly disagree; 5 = strongly agree) across four domains: coherency, factuality, comprehensiveness, and safety.

RESULTS

Across all themes and domains, median scores were all 4 ("agree"). Comprehensiveness had the lowest scores across domains (mean 3.8 ± 0.8), followed by factuality (mean 3.9 ± 0.8), safety (mean 4.1 ± 0.8) and coherency (mean 4.3 ± 0.7). Examination of the individual 37 questions showed that 5 (14%), 21 (57%), 23 (62%) and 9 (24%) of the questions had average scores below 4 (below "agree") for the coherency, factuality, comprehensiveness and safety domains, respectively. Free-text comments highlighted issues related to superseded or older technologies, and techniques that are not routinely used in clinical practice, such as genetic testing.

CONCLUSIONS

ChatGPT-4 responses to FAQs in AMD were generally agreeable in terms of coherency, factuality, comprehensiveness, and safety. However, areas of weakness were identified, precluding recommendations for routine use to provide patients with tailored counselling in AMD.

The impact of NF-κB on inflammatory and angiogenic processes in age-related macular degeneration

Age-related macular degeneration (AMD) is a prominent cause of vision loss, characterized by two different types, dry (atrophic) and wet (neovascular). Dry AMD is distinguished by the progressive deterioration of retinal cells, which ultimately causes a decline in vision. In contrast, wet AMD is defined by the abnormal development of blood vessels underneath the retina, leading to a sudden and severe vision impairment. The course of AMD is primarily driven by chronic inflammation and pathological angiogenesis, in which the NF-κB signaling pathway plays a crucial role. The activation of NF-κB results in the generation of pro-inflammatory cytokines, chemokines, and angiogenic factors like VEGF, which contribute to inflammation and the formation of new blood vessels in AMD. This review analyzes the intricate relationship between NF-κB signaling, inflammation, and angiogenesis in AMD and assesses the possibility of using NF-κB as a target for therapy. The evaluation involves a comprehensive examination of preclinical and clinical evidence that substantiates the effectiveness of NF-κB inhibitors in treating AMD by diminishing inflammation and pathological angiogenesis.

Effective health communication for age-related macular degeneration: An exploratory qualitative study

PURPOSE

Age-related macular degeneration (AMD) is a major cause of vision loss globally. Patients with AMD may not always understand or retain the information about AMD communicated by their eyecare practitioner. This study aims to explore the characteristics of effective health communication for AMD, from both patients' and eyecare practitioners' perspectives. The purpose is to provide a foundation for understanding how health communication for AMD could potentially be improved in the future.

METHODS

A total of 10 focus groups involving 17 patients with AMD and 17 optometrists were conducted via web conferencing. Each session was audio-recorded, transcribed and analysed using the Grounded Theory Methodology.

RESULTS

The five themes identified are as follows: (1) materials' quality, (2) materials' relevance, (3) contextualising for the individual, (4) contextualising for the disease and (5) support network. Participants expressed concern about the unrealistic yet common depiction of vision loss in AMD as a black patch overlying common visual scenes. They also preferred education materials tailored to a specific disease stage and the regular opportunity to ask or answer questions. Longer appointment durations and peer support (from family, friends or others with AMD) were also valued.

CONCLUSION

Optometrists are encouraged to focus on three over-arching dimensions when counselling patients with AMD in routine clinical practice: (1) curating and using disease and stage-specific, impactful education materials, (2) their chairside verbal communication techniques and (3) AMD-specific opportunities for care coordination among patient family and friends, peers and other multidisciplinary members of the care support team.

Short exposure to photo-oxidative damage triggers molecular signals indicative of early retinal degeneration

Introduction

Age-related macular degeneration (AMD) is the leading cause of blindness in the developed world, currently affecting over 350 billion people globally. For the most prevalent late-stage form of this disease, atrophic AMD, there are no available prevention strategies or treatments, in part due to inherent difficulties in early-stage diagnosis. Photo-oxidative damage is a well-established model for studying inflammatory and cell death features that occur in late-stage atrophic AMD, however to date has not been investigated as a potential model for studying early features of disease onset. Therefore, in this study we aimed to determine if short exposure to photo-oxidative damage could be used to induce early retinal molecular changes and advance this as a potential model for studying early-stage AMD.

Methods

C57BL/6J mice were exposed to 1, 3, 6, 12, or 24h photo-oxidative damage (PD) using 100k lux bright white light. Mice were compared to dim-reared (DR) healthy controls as well as mice which had undergone long periods of photo-oxidative damage (3d and 5d-PD) as known timepoints for inducing late-stage retinal degeneration pathologies. Cell death and retinal inflammation were measured using immunohistochemistry and qRT-PCR. To identify retinal molecular changes, retinal lysates were sent for RNA sequencing, following which bioinformatics analyses including differential expression and pathway analyses were performed. Finally, to investigate modulations in gene regulation as a consequence of degeneration, microRNA (miRNA) expression patterns were quantified using qRT-PCR and visualized using in situ hybridization.

Results

Short exposure to photo-oxidative damage (1-24h-PD) induced early molecular changes in the retina, with progressive downregulation of homeostatic pathways including metabolism, transport and phototransduction observed across this time-course. Inflammatory pathway upregulation was observed from 3h-PD, preceding observable levels of microglia/macrophage activation which was noted from 6h-PD, as well as significant photoreceptor row loss from 24h-PD. Further rapid and dynamic movement of inflammatory regulator miRNA, miR-124-3p and miR-155-5p, was visualized in the retina in response to degeneration.

Conclusion

These results support the use of short exposure to photo-oxidative damage as a model of early AMD and suggest that early inflammatory changes in the retina may contribute to pathological features of AMD progression including immune cell activation and photoreceptor cell death. We suggest that early intervention of these inflammatory pathways by targeting miRNA such as miR-124-3p and miR-155-5p or their target genes may prevent progression into late-stage pathology.

Optometrists' attitudes toward using OCT angiography lag behind other retinal imaging types

PURPOSE

While optometrists' attitudes toward established retinal imaging types are generally positive, they are unknown for optical coherence tomography angiography (OCTA). We performed a cross-sectional survey to estimate attitudes toward OCTA and identify clinician and/or practice characteristics that influence them.

METHODS

A paper-based survey was mailed to 252 randomly selected optometrists in Australia. Five-point Likert-scale items from a previous survey assessing attitudes toward new technology were included to probe respondent characteristics and attitudes toward retinal imaging. Performance expectancy attitudes toward OCTA were elicited by the statement 'I believe OCTA is useful in daily practice'. Mean scores out of five (mean [SD]) were rounded and mapped to appropriate descriptive statements.

RESULTS

The response rate was 47% (118/252). The mean (SD) age of respondents was 44.0 (13.8) years and 50.8% (60/118) were female. Optometrists had 19.9 (14.0) years of clinical experience and 66.9% (79/118) worked at independent practices. In total, 8.5% (10/118) of respondents used OCTA to provide clinical care. Optometrists agreed that optical coherence tomography (OCT), colour fundus imaging, ultra-wide field imaging and fundus autofluorescence (mean scores 3.6-4.7 out of 5) were useful in daily practice but felt neutral about whether OCTA was useful (3.4 [0.8]). Optometrists believed that OCTA was less enjoyable to use (p < 0.0001), less endorsed by peers (p < 0.0001) and felt less confident that they had the knowledge to interpret OCTA (p < 0.0001) compared to other retinal imaging types.

CONCLUSIONS

Optometrists are undecided on whether OCTA is useful in daily practice and had lower expectations that using OCTA would confer job performance benefits compared to other retinal imaging types. Further work is needed to advocate the benefits of using OCTA across the profession.

What Advice Is Currently Given to Patients with Age-Related Macular Degeneration (AMD) by Eyecare Practitioners, and How Effective Is It at Bringing about a Change in Lifestyle? A Systematic Review

There is currently no treatment for early/intermediate Age-related Macular Degeneration (AMD) but Eye Care Professionals (ECPs) are recommended to advise patients about modifiable lifestyle factors, including dietary changes, that can slow disease progression. The aim of this review was to understand advice currently given to patients with AMD by ECPs and to evaluate evidence regarding patient compliance. A systematic review was conducted of literature published in electronic databases: CINAHL, MEDLINE, PsycINFO, PyscARTICLES, EMBASE, AMED. Methods followed PRISMA guidelines (PROSPERO registration number: CRD42020223724). Twenty-four reports were eligible for inclusion, 12 focused on ECP experience, 7 on patient experience, and 6 on impact of advice (one paper reported on the ECP and patient experience). Studies reported that a substantial proportion of patients did not recall receiving lifestyle modification advice from their ECP (57.95%, range 2-95% across patient based studies). Practitioners were most likely to provide advice about nutritional supplements (80%, range 67-93% across ECP studies), and least likely about smoking (44%, range 28-71% across ECP studies), however supplements advised did not always comply with evidence-based guidelines. The main reason for patients not following lifestyle advice was lack of provision by the ECP (54.5%, range 21-94% across studies on the impact of advice). The review highlighted a need for more studies to understand patient preferences for receiving advice and research on ECP perceived barriers to advice provision.

Point‐of‐care tools to support optometric care provision to people with age‐related macular degeneration: A randomised, placebo‐controlled trial

Purpose

Age‐related macular degeneration (AMD) is a leading cause of vision impairment. This randomised placebo‐controlled trial investigated whether point‐of‐care tools can improve optometrists' AMD knowledge and/or care provision.

Methods

Australian optometrists (n = 31) completed a demographics survey and theoretical AMD case study multiple‐choice questions (MCQs) to assess their confidence in AMD care provision and AMD knowledge. Participants were then randomly assigned to one of three point‐of‐care tools (online ‘Classification of Age‐related macular degeneration and Risk Assessment Tool’ (CARAT), paper CARAT, or ‘placebo’) to use when providing care to their subsequent 5–10 AMD patients. Participants self‐audited the compliance of their AMD care to best practice for these patients, and a similar number of consecutive patients seen prior to enrolment. Post‐intervention, participants retook the AMD knowledge MCQs and confidence survey.

Results

A total of 29 participants completed the study. At the study endpoint, clinical confidence relative to baseline improved with the paper CARAT, relative to placebo, for knowledge of AMD risk factors, asking patients about these factors and referring for medical retinal sub‐specialist care. There were no between‐group differences for the change in AMD knowledge scores. Considering record documentation for patients with any AMD severity, there were no significant between‐group differences for documenting patient risk factors, AMD severity, clinical examination techniques or management. In a sub‐analysis, the change from baseline in compliance for documenting discussions about patient smoking behaviours for early AMD patients was higher with use of the online CARAT relative to placebo (p = 0.04). For patients with intermediate AMD, the change from baseline in documenting the risk of progression to late AMD was greater among practitioners who used the paper CARAT, relative to placebo (p = 0.04).

Conclusions

This study demonstrates that point‐of‐care clinical tools can improve practitioner confidence and aspects of the documentation of AMD clinical care by optometrists as assessed by self‐audit.

Clinical decision support in primary care for better diagnosis and management of retinal disease

Misdiagnosis of retinal disease is a common problem in primary care that can lead to irreversible vision loss and false-positive referrals, resulting in inappropriate use of health services. Clinical decision support systems describe tools that leverage information technology to provide timely recommendations that assist clinicians in the decisions they make about the care of a patient. They, therefore, have the potential to reduce the rate of misdiagnosis by promoting evidence-based medicine and more effective and efficient healthcare. This narrative review aims to support primary care practitioners in better understanding the current and emerging capacity of clinical decision support systems in eye care. Different types of clinical decision support systems are discussed, using current examples and evidence from the available literature to demonstrate how they may improve diagnostic effectiveness and aid the management of retinal disease. Comments are made on the future directions of clinical decision support in primary eye care and the potential applications of artificial intelligence.

Introduction of structured record keeping in age-related macular degeneration: a before and after study

CLINICAL RELEVANCE

Structured record keeping improves documentation in age-related macular degeneration; however, it may have a more limited effect on the management decisions of a group of already highly trained clinicians, especially in the context of other well-embedded clinical decision support tools.

BACKGROUND

Structured record keeping has been associated with a range of advantages including improved history taking and communication, reduced number of unnecessary referrals, and enhanced diagnostic accuracy. The aim of this study was to examine the impact of a structured record keeping, quality improvement tool on recording, reporting and management congruency.

METHODS

A before and after retrospective record review study was performed in a single academic, intermediate-tier care institute in New South Wales, Australia. The structured record keeping tool intervention captured 31 items in addition to the prior pre-existing medical record: six items relating to historical risk factors, two items relating to patient activation, 13 items signifying core clinical signs, five items for change analysis and five items regarding the ongoing patient management plan.

RESULTS

Two hundred medical records from 151 patients with age-related macular degeneration were analysed. There was a statistically significant improvement in the number of reports that explicitly specified the number of clinical structural risk factors (from 24 to 75%; Fisher's exact p < 0.001) and risk of progression to advanced disease (from 71 to 84%; p = 0.041); however, this documentation had no statistically significant effect on the report-recommended management plan and/or the final report-recommended review period.

CONCLUSION

Disease-specific, structured record keeping improves the outgoing documentation of key clinical signs and is effective in prompting the transposition of these signs into a quantified risk progression score. It has limited value in improving management consistency among a group of highly trained eye care staff.

Recent Advances and the Potential for Clinical Use of Autofluorescence Detection of Extra-Ophthalmic Tissues

The autofluorescence (AF) characteristics of endogenous fluorophores allow the label-free assessment and visualization of cells and tissues of the human body. While AF imaging (AFI) is well-established in ophthalmology, its clinical applications are steadily expanding to other disciplines. This review summarizes clinical advances of AF techniques published during the past decade. A systematic search of the MEDLINE database and Cochrane Library databases was performed to identify clinical AF studies in extra-ophthalmic tissues. In total, 1097 articles were identified, of which 113 from internal medicine, surgery, oral medicine, and dermatology were reviewed. While comparable technological standards exist in diabetology and cardiology, in all other disciplines, comparability between studies is limited due to the number of differing AF techniques and non-standardized imaging and data analysis. Clear evidence was found for skin AF as a surrogate for blood glucose homeostasis or cardiovascular risk grading. In thyroid surgery, foremost, less experienced surgeons may benefit from the AF-guided intraoperative separation of parathyroid from thyroid tissue. There is a growing interest in AF techniques in clinical disciplines, and promising advances have been made during the past decade. However, further research and development are mandatory to overcome the existing limitations and to maximize the clinical benefits.