Prevalence of serious eye disease and visual impairment in a north London population: population based, cross sectional study

Colorimetric and Photobiological Properties of Light Transmitted Through Low-Vision Filters: Simulated Potential Impact on ipRGCs Responses Considering Crystalline Lens Aging

This study aims to investigate the potential impact of commercial low-vision filters on intrinsically photosensitive retinal ganglion cells (ipRGCs), which have significantly advanced our understanding of non-image-forming visual functions. A comprehensive analysis by modeling the potential responses of ipRGCs to commercially available low-vision filters was conducted, focusing on how the spectral properties of these filters could alter ipRGC function. Additionally, the influence of aging on the crystalline lens was considered. Colorimetric changes in the transmitted light by these filters were also analyzed, highlighting variations based on the manufacturer. The study uncovered the diverse responses of ipRGCs to fifty low-vision filters, shedding light on the potential modifications in ipRGC stimulation and visual function. Notably, the consideration of aging in the crystalline lens revealed significant alterations in ipRGC response. Furthermore, the analysis of colorimetric changes demonstrated substantial differences in the light transmitted by these filters, with variations dependent on the manufacturer. This research underscores the nuanced relationship between low-vision filters and ipRGCs, providing insights into their potential impact on visual function. The varying responses observed, coupled with the influence of aging on the crystalline lens, emphasize the complexity of this interaction. Additionally, the distinct colorimetric changes based on filter manufacturer suggest the need for tailored approaches in enhancing visual perception for individuals with visual impairments.

DETECT: DEveloping and testing a model to identify preventive vision loss among older paTients in gEneral praCTice - protocol for a complex intervention in Denmark

INTRODUCTION

The number of people living with visual impairment is increasing. Visual impairment causes loss in quality of life and reduce self-care abilities. The burden of disease is heavy for people experiencing visual impairment and their relatives. The severity and progression of age-related eye diseases are dependent on the time of detection and treatment options, making timely access to healthcare critical in reducing visual impairment. General practice plays a key role in public health by managing preventive healthcare, diagnostics and treatment of chronic conditions. General practitioners (GPs) coordinate services from other healthcare professionals. More involvement of the primary sector could potentially be valuable in detecting visual impairment.

METHODS

We apply the Medical Research Council framework for complex interventions to develop a primary care intervention with the GP as a key actor, aimed at identifying and coordinating care for patients with low vision. The development process will engage patients, relatives and relevant health professional stakeholders. We will pilot test the feasibility of the intervention in a real-world general practice setting. The intervention model will be developed through a participatory approach using qualitative and creative methods such as graphical facilitation. We aim to explore the potentials and limitations of general practice in relation to detection of preventable vision loss.

ETHICS AND DISSEMINATION

Ethics approval is obtained from local authority and the study meets the requirements from the Declaration of Helsinki. Dissemination is undertaken through research papers and to the broader public through podcasts and patient organisations.

Association of alkaptonuria and low dose nitisinone therapy with cataract formation in a large cohort of patients

Homogentisic acid (HGA) lowering, disease modifying off-label nitisinone therapy has been used in the United Kingdom National Alkaptonuria Centre (NAC) since 2012. This study evaluated the serendipitous observation of cataract in a large cohort of patients with the very rare disease alkaptonuria (AKU), over a 5-year period. Patients with AKU who attended the NAC since 2012. Standard physical examination and ocular assessment, including photographs of the crystalline lens were taken before commencement of nitisinone 2 mg daily and annually over 5 years. Photographs were randomised and graded by two independent observers using the WHO cataract classification. AKU patients who did not receive nitisinone were included as a control group. HGA was measured on acidified 24 h urine (u-HGA24) and HGA and tyrosine in fasting acidified serum samples (sHGA, sTYR) at each visit. Patients without suitable lens images were excluded. Cataract (mean grade 1) was noted at baseline in 47 out of 62 (76%) with a mean (SD) age of 44 (14) years. In nitisinone-treated patients, there were significant increases in the mean grade of nuclear (0.18, p < 0.01) and cortical (0.38, p < 0.01) lens opacities over the mean duration of 4.93 years of the study. Worsening of the nuclear cataract and cortical lens opacities by at least 1 grade was noted in 14 out of 46 (30%) and 11 out of 46 (24%) patients, respectively. There is an increased prevalence and progression of cataract in AKU and a possible association of nitisinone with cataract progression.

Association of Visual Impairment with Psychological Distress in Older Adults: A Survey of 105,092 Older People in Taiwan

This study aimed to evaluate the association between visual impairment (VI) and psychological distress (PD) among older adults in Taiwan. The present cohort study included participants aged >65 years who participated in a physical examination program. Participants were divided into two groups on the basis of whether they had PD at baseline. The association between PD and VI with other variables was compared using the two-sample t-test for continuous variables and chi-squared test for discrete variables. Cox regression analyses were used to calculate the hazard ratio (HR). Cumulative incidence of PD was analyzed using the Kaplan-Meier method, and differences among participants with different severities of VI were analyzed using the two-tailed log-rank test. Subgroup analyses were performed to calculate the HR for PD among participants with different severities of VI. The PD group showed a significantly high percentage of VI. In addition, participants with VI showed a significantly higher HR and seven-year cumulative incidence rate of PD than those without VI. VI was independently and significantly associated with a higher incidence of PD among older Asian people. Therefore, identifying and treating correctible VI is important to prevent PD and improve the overall quality of life.

Role of advanced technology in the detection of sight-threatening eye disease in a UK community setting

Background/aims

To determine the performance of combinations of structural and functional screening tests in detecting sight-threatening eye disease in a cohort of elderly subjects recruited from primary care.

Methods

505 subjects aged ≥60 years underwent frequency doubling technology (FDT) perimetry, iVue optical coherence tomography (iWellness and peripapillary retinal nerve fibre layer (RNFL) scans) and intraocular pressure with the Ocular Response Analyzer, all performed by an ophthalmic technician. The reference standard was a full ophthalmic examination by an experienced clinician who was masked to the index test results. Subjects were classified as presence or absence of sight-threatening eye disease (clinically significant cataract, primary open-angle glaucoma, intermediate or advanced age-related macular degeneration and significant diabetic retinopathy). Univariate and multivariate logistic regression analyses were used to determine the association between abnormal screening test results and the presence of sight-threatening eye disease.

Results

171 subjects (33.8%) had one or more sight-threatening eye diseases. The multivariate analysis found significant associations with any of the target conditions for visual acuity of <6/12, an abnormal FDT and peripapillary RNFL thickness outside the 99% normal limit. The sensitivity of this optimised screening panel was 61.3% (95% CI 53.5 to 68.7), with a specificity of 78.8% (95% CI 74.0 to 83.1), a positive predictive value of 59.5% (95% CI 53.7 to 65.2) and an overall diagnostic accuracy of 72.9% (95% CI 68.8 to 76.8).

Conclusions

A subset of screening tests may provide an accurate and efficient means of population screening for significant eye disease in the elderly. This study provides useful preliminary data to inform the development of further larger, multicentre screening studies to validate this screening panel.

"I prefer a male nurse to a female nurse": patients' preference for, and satisfaction with nursing care provided by male nurses at the Komfo Anokye teaching hospital

Background

Although most male nurses join the profession for self-actualisation, the cultural and societal stereotyping of male nurses as “He-Man”, “gay” and “troublemakers”, and their marginalisation at the hospital during certain personal and intimate care procedures, tend to deepen the existing gender discrimination prevalent within the nursing profession. This study therefore assessed patients’ preference for, and satisfaction with nursing care provided by male nurses at the medical and surgical wards of Komfo Anokye Teaching Hospital [KATH].

Methods

An inferential cross-sectional study design, in which the prevalence of a condition among an identified population is determined, was used. Using convenience sampling, 150 respondents who meet certain practical criteria and are available and willing to participate were sampled. Data from a context-based research instrument on the opinion, preference and satisfaction of patients with male nursing were analysed using χ² test, Mann Whitney U test, ordinal logistic regression and logistic regression.

Results

The study indicates that more females than males had ever been attended to by a male nurse for the period considered by the study, and females described male nurses as polite and courteous and were comfortable with their treatment. Being single [OR = 0.111, 95% CI (0.013–0.928)] and professing Islamic faiths [OR = 36.533, 95% CI (2.116–630.597)] were functions of respondents’ preference for a male nurse. Significantly too, affiliating to a religious sect (OR = 2.347, 95% CI [0.076–1.630]) and being educated (OR = 1.387, 95% CI [0.040–0.615]), were associated with higher odds of falling in one of the higher categories of satisfaction with nursing care provided by male nurses as against the lower categories.

Conclusion

Although marital status, religious affiliation and educational level were the significant predictors of patients’ preference for, and satisfaction with care provided by male nurses, the effect of the other variables should not be overlooked. The finding disproves assertions on the negative effect of religion on male nurses. It is recommended that public awareness be created on the role of male nurses in the healthcare delivery system to promote acceptance of gender diversity in the nursing profession.

Ophthalmologic health status of an aging population-data from the Berlin Aging Study II (BASE-II)

PURPOSE

Vision of the elderly may be affected by typical age-related diseases like cataract and macular degeneration. Little is known about the effect of aging on visual difficulties and vision-related quality of life. This study was conducted to compare the ophthalmological health status of younger and older individuals within a large cohort study of residents of a greater metropolitan area (Berlin Aging Study II [BASE-II]).

METHODS

A total of 1655 participants (805 men) aged 60 years and older and 494 participants (232 men) aged between 22 and 48 years from the Berlin Aging Study II were included in the analysis. The subjects were examined during a 2-day clinical examination period. History of ocular diseases, vision-related quality of life using the visual function questionnaire (VFQ- 25), refraction, distance and near visual acuity, tonometry, and color vision were provided.

RESULTS

Older subjects performed significantly worse concerning distance and near visual acuity, color vision, and vision-related quality of life compared to young subjects. Intraocular pressure showed no significant difference between groups. Individuals are often unaware of existing eye diseases.

CONCLUSION

The prevalence of ocular diseases and the impairment of vision increases with age. Although 98% of elderly subjects have reported to suffer from any ocular disease, subjective quality of life seems to be affected to a lesser extent.

Patient behaviour in medication management: Findings from a patient usability study that may impact clinical outcomes

Aims

Adequate medication management is a key condition to ensuring effective pharmacotherapy. However, it is well acknowledged that older people may encounter difficulties self‐administering medicines in a correct manner.

Methods

A mixed method pilot study was performed to investigate medication self‐management in older and multimorbid patients with polypharmacy. The pilot study involved medication management tasks followed by semi‐structured interviews in 20 patients. The tasks and interviews were based on the patients' individual medication plans, which had been prepared earlier by the pharmacy for each patient on basis of all their prescriptions.

Results

The patients' self‐reported medication management skills differed from their actual observed medication management performance. In addition, the routines and coping strategies used by the patients to deal with the complexity of their overall medication regimen were not in accordance with the medication plan and the instructions for use on the product labels. Issues were observed on all stages of the medication process that can be considered relevant to patient adherence, especially medication plan recall, product identification, product selection, product handling and product recognition in a multicompartment compliance aid.

Conclusions

The pilot study suggested that medication management issues by older and multimorbid patients remain widely undetermined and unrecognized in primary care. Further investigation and interdisciplinary collaboration will be required to resolve the user problems and ensure adequate patient adherence.

Prevalence of treatment with glaucoma medication in Scotland, 2010-2017

AIMS

To report the number and demographic distribution of patients receiving intraocular pressure (IOP)-lowering medications across the whole population of Scotland for the years 2010-2017 and, using national census data, show how the observed changes compare with those predicted by the increasing age of the population structure over this period.

METHODS

Data were sourced from the Prescribing Information System of the NHS Information and Statistics Division for Scotland. The number of patients dispensed any IOP-lowering medication from a community pharmacy during each calendar year was collected by gender and by 5-year age bands. National census data were used to model the expected annual increase in treatment numbers due to population ageing.

RESULTS

The number of treated patients in 2017 was 61 249 which represents 1.13% of the whole population (or 2.16% over 40 years of age). The number increased from 48 178 in 2010-an increase over this period of 27.13% (3.88% per year).Prevalence increased with age, reaching 10.67% in those over 90 years. After age adjustment, more men were treated than women (OR 1.26).The expected number treated in 2017 based on census predictions was 54 075 (an increase of 5897 (12.24%) from 2010). The observed growth of 27.13% was 2.22-fold greater than the rate expected by population changes over the period 2010-2017.

CONCLUSION

The number of patients on medication for glaucoma and ocular hypertension in Scotland is increasing. The rate of increase cannot be explained by changes in the size and age structure of the population alone.

Budget impact model of Mydrane®, a new intracameral injectable used for intra-operative mydriasis, from a UK hospital perspective

BACKGROUND

During cataract surgery, maintaining an adequate degree of mydriasis throughout the entire operation is critical to allow for visualisation of the capsulorhexis and the crystalline lens. Good anaesthesia is also essential for safe intraocular surgery. Mydrane® is a new injectable intracameral solution containing two mydriatics (tropicamide 0.02% and phenylephrine 0.31%) and one anaesthetic (lidocaine 1%) that was developed as an alternative to the conventional topical pre-operative mydriatics used in cataract surgery. This study aimed to estimate the budget impact across a one year time frame using Mydrane® instead of topical dilating eye drops, for a UK hospital performing 3,000 cataract operations a year.

METHODS

A budget impact model (BIM) was developed to compare the economic outcomes associated with the use of Mydrane® versus topical drops (tropicamide 0.5% and phenylephrine 10%) in patients undergoing cataract surgery in a UK hospital. The outcomes of interest included costs and resource use (e.g. clinician time, mydriasis failures, operating room time, number of patients per vial of therapy etc.) associated with management of mydriasis in patients undergoing cataract surgery. All model inputs considered the UK hospital perspective without social or geographical variables. Deterministic sensitivity analyses were also performed to assess the model uncertainty.

RESULTS

Introduction of Mydrane® is associated with a cost saving of £6,251 over 3,000 cataract surgeries in one year. The acquisition costs of the Mydrane® (£18,000 by year vs. £3,330 for eye drops) were balanced by substantial reductions in mainly nurses' costs and time, plus a smaller contribution from savings in surgeons' costs (£20,511) and lower costs associated with auxiliary dilation (£410 due to avoidance of additional dilation methods). Results of the sensitivity analyses confirmed the robustness of the model to the variation of inputs. Except for the duration of one session of eye drop instillation and the cost of Mydrane®, Mydrane® achieved an incremental cost gain compared to tropicamide/phenylephrine eye drops.

CONCLUSIONS

Despite a higher acquisition cost of Mydrane®, the budget impact of Mydrane® on hospital budgets is neutral. Mydrane® offers a promising alternative to traditional regimes using eye drops, allowing for a better patient flow and optimisation of the surgery schedule with neutral budget impact.

Number of incident cases of the main eye diseases of ageing in the UK Biobank cohort, projected over a 25-year period from time of recruitment

OBJECTIVES

To estimate the number of new cases of age-related macular degeneration, cataract and glaucoma accruing in the UK Biobank cohort, over a period of 25 years from time of recruitment. Our secondary objective was to assess the statistical power of nested case-control studies of these eye diseases. We aimed to provide quantitative information relevant to UK Biobank's eye disease case ascertainment efforts and to the potential for UK Biobank-based research into the causes of eye disease.

METHODS

We constructed a Markov discrete-time state transition model to simulate the population dynamics of the eye disorders within the UK Biobank cohort, using prevalence data from population-based epidemiological studies to derive incidence, and Office for National Statistics data on mortality and migration overseas.

RESULTS

By 2023, >900 new cases of each of 'wet' (neovascular) and 'dry' age-related macular degeneration, >1200 cases of primary open angle glaucoma and almost 15 000 cases of cataracts are expected to have accrued in the subcohort of 68 500 participants who had ocular assessment at baseline, with around seven times as many cases of each disease in the whole cohort of 500 000 participants. These predicted incident case numbers generate good or substantial statistical power for a range of nested case-control studies of potential genetic, lifestyle and environmental determinants of disease.

CONCLUSIONS

Over the next few years, UK Biobank is expected to generate sufficient numbers of new cases for statistically well-powered studies of the determinants of the major causes of sight loss: age-related macular degeneration, vision-impairing cataract and glaucoma.

The economic impact of sight loss and blindness in the UK adult population

BACKGROUND

To quantify the economic impact of sight loss and blindness in the United Kingdom (UK) population, including direct and indirect costs, and its burden on health.

METHODS

Prevalence data on sight loss and blindness by condition, Census demographic data, data on indirect costs, and healthcare cost databases were used. Blindness was defined as best corrected visual acuity (BCVA) of < 6/60, and sight loss as BCVA < 6/12 to 6/60, in the better-seeing eye.

RESULTS

Sight loss and blindness from age-related macular degeneration (AMD), cataract, diabetic retinopathy, glaucoma and under-corrected refractive error are estimated to affect 1.93 (1.58 to 2.31) million people in the UK. Direct health care system costs were £3.0 billion, with inpatient and day care costs comprising £735 million (24.6%) and outpatient costs comprising £771 million (25.8%). Indirect costs amounted to £5.65 (5.12 to 6.22) billion. The value of the loss of healthy life associated with sight loss and blindness was estimated to be £19.5 (15.9 to 23.3) billion or £7.2 (5.9 to 8.6) billion, depending on the set of disability weights used. For comparison with other published results using 2004 disability weights and the 2008 estimates, the total economic cost of sight loss and blindness was estimated to be £28.1 (24.0 to 32.5) billion in 2013. Using 2010 disability weights, the estimated economic cost of sight loss and blindness was estimated to be £15.8 (13.5 to 18.3) billion in 2013.

CONCLUSIONS

The large prevalence of sight loss and blindness in the UK population imposes significant costs on public funds, private expenditure, and health. Prevalence estimates relied on dated epidemiological studies and may not capture recent advances in treatment, highlighting the need for population-based studies that track the prevalence of sight-impairing eye conditions and treatment effects over time.

Glaucoma and intraocular pressure in EPIC-Norfolk Eye Study: cross sectional study

Objectives To report the distribution of intraocular pressure (IOP) by age and sex and the prevalence of glaucoma.Design Community based cross sectional observational study.Setting EPIC-Norfolk cohort in Norwich and the surrounding rural and urban areas.Participants 8623 participants aged 48-92 recruited from the community who underwent ocular examination to identify glaucoma.Main outcome measures Prevalence and characteristics of glaucoma, distribution of IOP, and the sensitivity and specificity of IOP for case finding for glaucoma.Results The mean IOP in 8401 participants was 16.3 mm Hg (95% confidence interval 16.2 mm Hg to 16.3 mm Hg; SD 3.6 mm Hg). In 363 participants (4%), glaucoma was present in either eye; 314 (87%) had primary open angle glaucoma. In the remaining participants, glaucoma was suspected in 607 (7%), and 863 (10.0%) had ocular hypertension. Two thirds (242) of those with glaucoma had previously already received the diagnosis. In 76% of patients with newly diagnosed primary open angle glaucoma (83/107), the mean IOP was under the threshold for ocular hypertension (21 mm Hg). No one IOP threshold provided adequately high sensitivity and specificity for diagnosis of glaucoma.Conclusions In this British community, cases of glaucoma, suspected glaucoma, and ocular hypertension represent a large number of potential referrals to the hospital eye service. The use of IOP for detection of those with glaucoma is inaccurate and probably not viable.

Prevalence and causes of low vision and blindness in a Chinese population with type 2 diabetes: the Dongguan Eye Study

To assess the prevalence and causes of low vision and blindness in type 2 diabetes patients, a population-based cross-sectional study including 8952 rural-dwelling residents aged 40 years or older from Hengli Town in Southern China was conducted. Participants underwent standard interviews, physical measurements, laboratory tests, and comprehensive eye examinations. Low vision and blindness were defined based on WHO criteria. Visual acuity data were available for 1348 (89.9%) of the 1500 subjects with type 2 diabetes. Age-standardized prevalence of bilateral low vision and blindness assessed in the better-seeing eye was 2.9% (95% confidence interval [CI]: 2.0–3.8) and 0.7% (95% CI: 0.2–1.1) based on best-corrected visual acuity (BCVA). Cataracts were the primary cause of low vision and blindness. Visual impairment was associated with age (odds ratio [OR]: 3.73, 95% CI: 2.39–5.83), education level (OR: 3.21, 95% CI: 1.63–6.29), duration of diabetes (OR: 1.14, 95% CI: 1.04–1.25) and body mass index (OR: 0.86, 95% CI: 0.77–0.95). Our data suggest that approximately 70% of visual impairment in this diabetic population could be eliminated with appropriate cataract surgery or spectacle correction. Greater consideration should be given to older type 2 diabetes patients with a level of lower education.

Prevalence of age-related macular degeneration in an elderly UK Caucasian population-The Bridlington Eye Assessment Project: a cross-sectional study

ImportanceThere is paucity of data on prevalence and disease asymmetry of age-related macular degeneration (AMD), particularly the earlier stages, in the UK population.Objective and PurposeTo determine the prevalence of age-related macular degeneration in an elderly Caucasian UK population.DesignCross-sectional population study, 2002-2006.ParticipantsResidents in the study area of Bridlington aged 65 years and older.MethodsFull-ophthalmic examination was undertaken in 3549 participants, of eligible 6319 Caucasian population (response rate of 56%). Non-stereoscopic Colour fundus photographs (30°) were graded masked using a modified Rotterdam Classification for 3475 (98%) participants with gradable images. Prevalence for different AMD grades were calculated. Demographic details were analysed then integrated with the AMD gradings for full analysis. Prevalence rates for the different AMD Grades were calculated, as well as the age-specific prevalences.ResultsAMD prevalence in the worst eye were 38.5% grade 0, 41.4% grade 1, 12.8% grade 2, 2.8% grade 3, and 4.6% grade 4. Geographic atrophy (grade 4a) occurred in 2.5%, and neovascular AMD (grade 4b) in 1.8%. Prevalence increased with age such that grade 4 (advanced) AMD was 2.2% in the 65-69 years group, 15.8% for the 85-90, and 21.2% for over 90 years. There was significant asymmetry between the two eyes of individuals with advanced AMD (P<0.001), such that vision loss was unilateral. Persons with more advanced AMD grades were more likely to be dissatisfied with their vision.ConclusionsAdvanced AMD occurs more commonly in the UK Caucasian population than previously reported. Significant asymmetry between the two eyes occurs in individuals with unilateral advanced AMD so that visual impairment statistics do not represent true prevalence of advanced AMD. Persons with more advanced AMD were more likely to be dissatisfied with their vision.

Prevalence and the risk factors for visual impairment in age-related macular degeneration

PurposeTo characterize the type, and the causes of visual impairment (VI) in various stages of early and late age-related macular degeneration (AMD) and the factors associated with visual impairment in subjects with AMDMethods6617 subjects ≥60 years were enumerated; 5495 (83.04%) participated in eye examination. Of which, 4791 subjects had gradable fundus images. AMD was graded per International ARM Epidemiological Study Group. Subjects underwent detailed ophthalmic exam. VI was defined per the WHO classification. Mild VI was defined as VA less than 6/12 to 6/18, moderate VI-VA less than 6/18 but up to 6/60, severe VI-VA less than 6/60 but up to 3/60 and legal blindness-VA worse than 3/60. Factors associated with VI in AMD was analyzed with univariate and logistic regression analysis.ResultsNine hundred and eighty-eight subjects were identified as having AMD (893 with early AMD and 95 with late AMD); 85% of the subjects (95% CI: 82.7-87.1) had no VI, 13.1% had mild VI (95% CI: 11.1-15.3), 0.8% had severe VI (95% CI: 0.4-1.6), 1.1% had legal blindness (95% CI: 0.6-1.9). Prevalence of any VI was 13.7% in early AMD and 27.4% in late AMD, P=0.0004; age group 65-70 years (OR=1.89, 95% CI: 1.16-3.08, P=0.011), and those ≥75 years (OR=3.67, 95% CI: 1.95-6.91, P=0.0001) had greater odds of VI compared with age group 60-64 years. Male gender was a protective factor for VI (OR=0.57, CI: 0.36-0.90, P=0.016). Cataract (31.8%) and refractive error (28.4%) accounted for a majority of the VI.ConclusionsCataract and refractive error account for a significant proportion of VI in the south Indian population with AMD. Early AMD is the third leading cause of VI. Greater age and female gender are associated with VI in subjects with AMD.

Prevalence of ocular defects among patients visiting in an institutionalized hospital setting: A cross-sectional study

Purpose:

The purpose of this study was to analyze the prevalence of ocular defect among different age groups, gender, side involved, and etiology.

Materials and Methods:

A retrospective study was conducted among referred ocular defect patients in a dental college in southern part of India over a 5 years period (2008–2012). Information regarding general identification, gender, age, affected side, and etiology was collected. The collected data were analyzed and grouped according to different age groups, gender, side involved, and etiology.

Results:

The ocular defects were more frequently observed in the young male population (66%). Trauma (46%) and pathogenic (44%) causes were the main reasons over nonspecific (8%) and congenital (2%) reasons.

Conclusion:

High prevalence of injuries and infections in young adults (mostly males) predominantly causing ocular bulb loss.

Automated imaging technologies for the diagnosis of glaucoma: a comparative diagnostic study for the evaluation of the diagnostic accuracy, performance as triage tests and cost-effectiveness (GATE study)

BACKGROUND

Many glaucoma referrals from the community to hospital eye services are unnecessary. Imaging technologies can potentially be useful to triage this population.

OBJECTIVES

To assess the diagnostic performance and cost-effectiveness of imaging technologies as triage tests for identifying people with glaucoma.

DESIGN

Within-patient comparative diagnostic accuracy study. Markov economic model comparing the cost-effectiveness of a triage test with usual care.

SETTING

Secondary care.

PARTICIPANTS

Adults referred from the community to hospital eye services for possible glaucoma.

INTERVENTIONS

Heidelberg Retinal Tomography (HRT), including two diagnostic algorithms, glaucoma probability score (HRT-GPS) and Moorfields regression analysis (HRT-MRA); scanning laser polarimetry [glaucoma diagnostics (GDx)]; and optical coherence tomography (OCT). The reference standard was clinical examination by a consultant ophthalmologist with glaucoma expertise including visual field testing and intraocular pressure (IOP) measurement.

MAIN OUTCOME MEASURES

(1) Diagnostic performance of imaging, using data from the eye with most severe disease. (2) Composite triage test performance (imaging test, IOP measurement and visual acuity measurement), using data from both eyes, in correctly identifying clinical management decisions, that is 'discharge' or 'do not discharge'. Outcome measures were sensitivity, specificity and incremental cost per quality-adjusted life-year (QALY).

RESULTS

Data from 943 of 955 participants were included in the analysis. The average age was 60.5 years (standard deviation 13.8 years) and 51.1% were females. Glaucoma was diagnosed by the clinician in at least one eye in 16.8% of participants; 37.9% of participants were discharged after the first visit. Regarding diagnosing glaucoma, HRT-MRA had the highest sensitivity [87.0%, 95% confidence interval (CI) 80.2% to 92.1%] but the lowest specificity (63.9%, 95% CI 60.2% to 67.4%) and GDx had the lowest sensitivity (35.1%, 95% CI 27.0% to 43.8%) but the highest specificity (97.2%, 95% CI 95.6% to 98.3%). HRT-GPS had sensitivity of 81.5% (95% CI 73.9% to 87.6%) and specificity of 67.7% (95% CI 64.2% to 71.2%) and OCT had sensitivity of 76.9% (95% CI 69.2% to 83.4%) and specificity of 78.5% (95% CI 75.4% to 81.4%). Regarding triage accuracy, triage using HRT-GPS had the highest sensitivity (86.0%, 95% CI 82.8% to 88.7%) but the lowest specificity (39.1%, 95% CI 34.0% to 44.5%), GDx had the lowest sensitivity (64.7%, 95% CI 60.7% to 68.7%) but the highest specificity (53.6%, 95% CI 48.2% to 58.9%). Introducing a composite triage station into the referral pathway to identify appropriate referrals was cost-effective. All triage strategies resulted in a cost reduction compared with standard care (consultant-led diagnosis) but with an associated reduction in effectiveness. GDx was the least costly and least effective strategy. OCT and HRT-GPS were not cost-effective. Compared with GDx, the cost per QALY gained for HRT-MRA is £22,904. The cost per QALY gained with current practice is £156,985 compared with HRT-MRA. Large savings could be made by implementing HRT-MRA but some benefit to patients will be forgone. The results were sensitive to the triage costs.

CONCLUSIONS

Automated imaging can be effective to aid glaucoma diagnosis among individuals referred from the community to hospital eye services. A model of care using a triage composite test appears to be cost-effective.

FUTURE WORK

There are uncertainties about glaucoma progression under routine care and the cost of providing health care. The acceptability of implementing a triage test needs to be explored.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Ophthalmologic evaluation in geriatric patients: Assessment of consistency between patients' complaints and ocular diagnoses

PURPOSE

This study aimed to assess the consistency between patients' complaints and their eye diseases.

DESIGN

Cross-sectional study.

METHODS

RESULTS: The frequencies of at least one newly diagnosed visually important ocular disease were 25.9%, 27.0%, and 45.3% in groups 1, 2, and 3, respectively (p<0.001). The same frequencies were significantly higher in patients >75 years of age compared with the younger group (59.1% vs. 22.0%, p<0.001). Although these values were statistically significant in patients ≤75 years of age (p<0.001), they were insignificant in patients >75 years of age according to type of complaints (p=0.773). Patients with diabetes mellitus exhibited significantly lower vision, higher rate of visually important ocular diseases, and higher intraocular pressure readings than patients without diabetes mellitus (p=0.009, 0.015, and 0.002, respectively).

CONCLUSIONS

Visually important ocular diseases were diagnosed approximately in a quarter of patients who had no complaints about decrease in vision and in more than half of the oldest geriatric patients (>75years) irrespective of the type of complaints.

The prevalence and risk factors of visual impairment among the elderly in Eastern Taiwan

Visual impairment is associated with disability and poor quality of life. This study aimed to investigate the prevalence and associated risk factors of visual impairment among the suburban elderly in Eastern Taiwan. The cross-sectional research was conducted from April 2012 to August 2012. The ocular condition examination took place in suburban areas of Hualien County. Medical records from local infirmaries and questionnaires were utilized to collect demographic data and systemic disease status. Logistic regression models were used for the simultaneous analysis of the association between the prevalence of visual impairment and risk factors. Six hundred and eighty-one residents participated in this project. The mean age of the participants was 71.4±7.3 years. The prevalence of vision impairment (better eye<6/18) was 11.0%. Refractive error and cataract were the main causes of vision impairment. Logistic regression analysis showed that people aged 65-75 years had a 3.8 times higher risk of developing visual impairment (p=0.021), while the odds ratio of people aged > 75 years was 10.0 (p<0.001). In addition, patients with diabetic retinopathy had a 3.7 times higher risk of developing visual impairment (p=0.002), while the odds ratio of refractive error was 0.36 (p<0.001). The prevalence of visual impairment was relatively high compared with previous studies. Diabetic retinopathy was an important risk factor of visual impairment; by contrast, refractive error was beneficial to resist visual impairment. Therefore, regular screening of ocular condition and early intervention might aid in the prevention of avoidable vision loss.

The Prevalence of Visual Impairment in People with Dementia (the PrOVIDe study): a cross-sectional study of people aged 60–89 years with dementia and qualitative exploration of individual, carer and professional perspectives

Background

The prevalence of visual impairment (VI) and dementia increases with age and these conditions may coexist, but few UK data exist on VI among people with dementia.

Objectives

To measure the prevalence of eye conditions causing VI in people with dementia and to identify/describe reasons for underdetection or inappropriate management.

Design

Stage 1 – cross-sectional prevalence study. Stage 2 – qualitative research exploring participant, carer and professional perspectives of eye care.

Setting

Stage 1 – 20 NHS sites in six English regions. Stage 2 – six English regions.

Participants

Stage 1 – 708 participants with dementia (aged 60–89 years): 389 lived in the community (group 1) and 319 lived in care homes (group 2). Stage 2 – 119 participants.

Interventions

Stage 1 gathered eye examination data following domiciliary sight tests complying with General Ophthalmic Services requirements and professional guidelines. Cognitive impairment was assessed using the Standardised Mini-Mental State Examination (sMMSE) test, and functional ability and behaviour were assessed using the Bristol Activities of Daily Living Scale and Cambridge Behavioural Inventory – Revised. Stage 2 involved individual interviews (36 people with dementia and 11 care workers); and separate focus groups (34 optometrists; 38 family and professional carers).

Main outcome measures.

VI defined by visual acuity (VA) worse than 6/12 or worse than 6/18 measured before and after refraction.

Results

Stage 1 – when participants wore their current spectacles, VI prevalence was 32.5% [95% confidence interval (CI) 28.7% to 36.5%] and 16.3% (95% CI 13.5% to 19.6%) for commonly used criteria for VI of VA worse than 6/12 and 6/18, respectively. Of those with VI, 44% (VA < 6/12) and 47% (VA < 6/18) were correctable with new spectacles. Almost 50% of remaining uncorrectable VI (VA < 6/12) was associated with cataract, and was, therefore, potentially remediable, and one-third was associated with macular degeneration. Uncorrected/undercorrected VI prevalence (VA < 6/12) was significantly higher in participants in care homes (odds ratio 2.19, 95% CI 1.30 to 3.73;p < 0.01) when adjusted for age, sex and sMMSE score. VA could not be measured in 2.6% of group 1 and 34.2% of group 2 participants (p < 0.01). The main eye examination elements (excluding visual fields) could be performed in > 80% of participants. There was no evidence that the management of VI in people with dementia differed from that in older people in general. Exploratory analysis suggested significant deficits in some vision-related aspects of function and behaviour in participants with VI. Stage 2 key messages – carers and care workers underestimated how much can be achieved in an eye examination. People with dementia and carers were unaware of domiciliary sight test availability. Improved communication is needed between optometrists and carers; optometrists should be informed of the person’s dementia. Tailoring eye examinations to individual needs includes allowing extra time. Optometrists wanted training and guidance about dementia. Correcting VI may improve the quality of life of people with dementia but should be weighed against the risks and burdens of undergoing examinations and cataract surgery on an individual basis.

Limitations

Sampling bias is possible owing to quota-sampling and response bias.

Conclusions

The prevalence of VI is disproportionately higher in people with dementia living in care homes. Almost 50% of presenting VI is correctable with spectacles, and more with cataract surgery. Areas for future research are the development of an eye-care pathway for people with dementia; assessment of the benefits of early cataract surgery; and research into the feasibility of specialist optometrists for older people.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Estimates of the number of older people with a visual impairment in the UK

One of the key challenges to policy-makers and service providers charged with tackling social exclusion is knowing who and how many people their policies should be addressing. What is required are reliable estimates of the target population. This article considers two key studies that have made it possible to produce estimates of the size of the older visually impaired population in the UK. It concludes that there are between about 1.6m and 2.2m people aged 65 years and over in the UK with visual acuity ranging from mild to serious levels of visual impairment. About half of visually impaired older people fall into the category of mild vision impairment (6/12 — 6/18). The other half has a moderate to severe visual impairment (VA < 6/18). Women aged 65 years and over with moderate or severe visual impairment outnumber visually impaired men by nearly three to one. Of those aged 75 years and over with moderate to severe visual impairment, about half of them have cataracts or refractive error, many of whom could have treatment or intervention which would considerably improve their vision. There are also an estimated 300,000 people aged 75 years and over in the UK with registerable eye conditions.

Socioeconomic Disparities in Cataract Prevalence, Characteristics, and Management

PURPOSE

To review the current literature on socioeconomic disparities relationship with cataract prevalence, characteristics, and management.

SUMMARY

Cataracts are an important cause of preventable visual impairment in both the developing and industrialized world. Cataract surgery is a highly effective operation with an excellent risk profile. Furthermore, cataract surgery has been shown to have significant positive functional, social, and economic implications for patients. Several medical conditions have been shown to have correlation with socioeconomic factors and cataract is among several forms of visual impairment that demonstrate this relationship. Disparities in prevalence, clinical characteristics, and management are documented in the ophthalmic literature. A better understanding of these socioeconomic factors and their clinical relevance is critical to alleviating the burden of cataract-related visual impairment in an aging population.

The Correlation of Age and Postoperative Visual Acuity for Age-Related Cataract

Purpose. Clinically, what is the best time for age-related cataract (ARC) patients to receive surgeries and get the most benefits is important. We explored the relationship between age and presenting postoperative visual acuity (POVA) in patients from rural China. Methods. Three Lifeline Express Hospital Eye-Train missions of Peking University People's Hospital were chosen. At the first day after surgery, 3452 ARC eyes with the presenting POVA ≥ 6/60 were enrolled. The relationship between age and POVA was analyzed statistically. Results. In these three missions, there were more female patients than males; the ratio of females to males was 1.71. The average age of females was older than males. Overall, the percentages of patients with good visual outcomes (≥6/18) were significantly decreased with aging. Different regions had variations, but the trends were the same. There was weak linear correlation between age and POVA. The correlations of females were stronger than males in Yuncheng and Sanmenxia and weaker than males in Zhoukou. Conclusion. The good visual outcomes of presenting POVA were significantly decreased with aging and there were weak linear correlations between age and POVA in rural China. The linear correlation might be influenced by the difference of gender and region.

Diagnostic Accuracy of Technologies for Glaucoma Case-Finding in a Community Setting

PURPOSE

To assess case-finding performance of the Frequency Doubling Technology Perimeter (FDT) (Carl Zeiss Meditec, Inc., Dublin, CA), Moorfields Motion Displacement Test (MMDT) (Moorfields Eye Hospital, London, UK), iVue optical coherence tomography (OCT) (Optovue Inc., Fremont, CA), and ocular response analyzer (ORA) (Reichert Ophthalmic Instruments, Depew, NY), alone or combined, for primary open-angle glaucoma (POAG).

DESIGN

Cross-sectional, observational, community-based study.

PARTICIPANTS

A total of 505 subjects aged ≥60 years recruited from a community setting using no predefined exclusion criteria.

METHODS

Subjects underwent 4 index tests conducted by a technician unaware of subjects' ocular status. FDT and MMDT were used in suprathreshold mode. iVue OCT measured ganglion cell complex and retinal nerve fiber layer (RNFL) thickness. Reference standard was full ophthalmic examination by an experienced clinician who was masked to index test results. Subjects were classified as POAG (open drainage angle, glaucomatous optic neuropathy, and glaucomatous field defect), glaucoma suspect, ocular hypertension, or non-POAG/nonocular hypertension.

MAIN OUTCOME MEASURES

Test performance evaluated the individual as the unit of analysis. Diagnostic accuracy was assessed using predefined cutoffs for abnormality, generating sensitivity, specificity, and likelihood ratios. Continuous data were used to derive estimates of sensitivity at 90% specificity and partial area under the receiver operating characteristic curve (AUROC) plots from 90% to 100% specificity.

RESULTS

From the reference standard examination, 26 subjects (5.1%) had POAG and 32 subjects (6.4%) were glaucoma suspects. Sensitivity (95% confidence interval) at 90% specificity for detection of glaucoma suspect/POAG combined was 41% (28-55) for FDT, 35% (21-48) for MMDT, and 57% (44-70) for best-performing OCT parameter (inferior quadrant RNFL thickness); for POAG, sensitivity was 62% (39-84) for FDT, 58% (37-78) for MMDT, and 83% (68-98) for inferior quadrant RNFL thickness. Partial AUROC was significantly greater for inferior RNFL thickness than visual-function tests (P < 0.001). Post-test probability of glaucoma suspect/POAG combined and definite POAG increased substantially when best-performing criteria were combined for FDT or MMDT, iVue OCT, and ORA.

CONCLUSIONS

Diagnostic performance of individual tests gave acceptable accuracy for POAG detection. Low specificity of visual-function tests precludes their use in isolation, but case detection improves by combining RNFL thickness analysis with visual function tests.

The clinical effectiveness and cost-effectiveness of second-eye cataract surgery: a systematic review and economic evaluation

BACKGROUND

Elective cataract surgery is the most commonly performed surgical procedure in the NHS. In bilateral cataracts, the eye with greatest vision impairment from cataract is operated on first. First-eye surgery can improve vision and quality of life. However, it is unclear whether or not cataract surgery on the second eye provides enough incremental benefit to be considered clinically effective and cost-effective.

OBJECTIVE

To conduct a systematic review of clinical effectiveness and analysis of cost-effectiveness of second-eye cataract surgery in England and Wales, based on an economic model informed by systematic reviews of cost-effectiveness and quality of life.

DATA SOURCES

Twelve electronic bibliographic databases, including MEDLINE, EMBASE, Web of Science, The Cochrane Library and the Centre for Reviews and Dissemination databases were searched from database inception to April 2013, with searches updated in July 2013. Reference lists of relevant publications were also checked and experts consulted.

REVIEW METHODS

Two reviewers independently screened references, extracted and checked data from the included studies and appraised their risk of bias. Based on the review of cost-effectiveness, a de novo economic model was developed to estimate the cost-effectiveness of second-eye surgery in bilateral cataract patients. The model is based on changes in quality of life following second-eye surgery and includes post-surgical complications.

RESULTS

Three randomised controlled trials (RCTs) of clinical effectiveness, three studies of cost-effectiveness and 10 studies of health-related quality of life (HRQoL) met the inclusion criteria for the systematic reviews and, where possible, were used to inform the economic analysis. Heterogeneity of studies precluded meta-analyses, and instead data were synthesised narratively. The RCTs assessed visual acuity, contrast sensitivity, stereopsis and several measures of HRQoL. Improvements in binocular visual acuity and contrast sensitivity were small and unlikely to be of clinical significance, but stereopsis was improved to a clinically meaningful extent following second-eye surgery. Studies did not provide evidence that second-eye surgery significantly affected HRQoL, apart from an improvement in the mental health component of HRQoL in one RCT. In the model, second-eye surgery generated 0.68 incremental quality-adjusted life-years with an incremental cost-effectiveness ratio of £1964. Model results were most sensitive to changes in the utility gain associated with second-eye surgery, but otherwise robust to changes in parameter values. The probability that second-eye surgery is cost-effective at willingness-to-pay thresholds of £10,000 and £20,000 is 100%.

LIMITATIONS

Clinical effectiveness studies were all conducted more than 9 years ago. Patients had good vision pre surgery which may not represent all patients eligible for second-eye surgery. For some vision-related patient-reported outcomes and HRQoL measures, thresholds for determining important clinical effects are either unclear or have not been determined.

CONCLUSIONS

Second-eye cataract surgery is generally cost-effective based on the best available data and under most assumptions. However, more up-to-date data are needed. A well-conducted RCT that reflects current populations and enables the estimation of health state utility values would be appropriate. Guidance is required on which vision-related, patient-reported outcomes are suitable for assessing effects of cataract surgery in the NHS and how these measures should be interpreted clinically.

STUDY REGISTRATION

This project is registered as PROSPERO CRD42013004211.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme.

Intravitreal combination of dexamethasone sodium phosphate and bevacizumab in the treatment of exudative AMD

The purpose of this study is to investigate the efficacy and safety of intravitreal dexamethasone sodium phosphate (DSP) combined with bevacizumab for the treatment of neovascular age-related macular degeneration (AMD). In this non comparative case study, 30 eyes of 27 patients with CNV due to AMD received intravitreal DSP (0.2 mg) and bevacizumab (1.25 mg) during a 6-month PRN (pro re nata) dosing regimen. Visual acuity, macular thickness and intraocular pressure (IOP) were monitored and recorded. After 6 months, mean retinal thickness decreased from 423.5 ± 75.3 to 228.2 ± 34.5 and mean visual acuity improved from 0.9 ± 0.39 logMAR to 0.53 ± 0.34 (p = 0.001) logMAR. During the trial period, 81 intravitreal injections were performed in 30 eyes, thus the mean number of injections per eye was 2.7 ± 1.1. 86.7% of the eyes required 3 or less injections while only 13.3% needed 4 or more injections. None of the patients, phakic or pseudophakic, manifested an elevation of IOP during the treatment, ranging between 12 and 22 mmHg. Combined DSP and bevacizumab offers encouraging results in the challenge of AMD treatment, providing immediate response of macular edema, reduced number of intravitreal injections and stabilization or improvement of visual acuity.

Heuristics in primary care for recognition of unreported vision loss in older people: a technology development study

AIM

To evaluate heuristics (rules of thumb) for recognition of undetected vision loss in older patients in primary care.

BACKGROUND

Vision loss is associated with ageing, and its prevalence is increasing. Visual impairment has a broad impact on health, functioning and well-being. Unrecognised vision loss remains common, and screening interventions have yet to reduce its prevalence. An alternative approach is to enhance practitioners' skills in recognising undetected vision loss, by having a more detailed picture of those who are likely not to act on vision changes, report symptoms or have eye tests. This paper describes a qualitative technology development study to evaluate heuristics for recognition of undetected vision loss in older patients in primary care.

METHOD

Using a previous modelling study, two heuristics in the form of mnemonics were developed to aid pattern recognition and allow general practitioners to identify potential cases of unreported vision loss. These heuristics were then analysed with experts. Findings It was concluded that their implementation in modern general practice was unsuitable and an alternative solution should be sort.

Outcomes of primary lymphoma of the ocular adnexa (orbital lymphoma) treated with radiotherapy

AIMS

Low-grade ocular adnexal lymphoma is a rare disease and often treated with local radiotherapy to varying doses. Most previously reported studies have a very heterogeneous patient population and treatments. We report the outcomes from a 10 year cohort of patients at our institution treated with primary radiation therapy.

MATERIALS AND METHODS

We analysed a retrospective case series of patients with stage IE low-grade ocular adnexal lymphoma including a review of case notes, histological reports and radiotherapy charts. We assessed local and distant tumour control and relapse rates in addition to toxicity. Disease-free survival was estimated using the Kaplan-Meier method.

RESULTS

In total, 81 patients and 85 orbits were treated with primary radiotherapy to a median dose of 30 Gy in 15 fractions over 3 weeks. Seventy-nine per cent were treated with standard MV external beam radiotherapy to the whole orbit and 21% with a lens-sparing technique. The median follow-up was 4.4 years (range 0.2-10.4). Local control rates were 100%, with 5% of patients experiencing disease relapse elsewhere. No patients died from lymphoma. Cumulative acute toxicity rates were 51% (mainly erythema and conjunctivitis) and late toxicity rates were 8% (mainly cataract). The lens-sparing technique was associated with a significant reduction in cataract rate (P = 0.013) and an increase in acute toxicity (P < 0.001).

CONCLUSIONS

This study has shown excellent local control rates and acceptable toxicity from the treatment of stage IE low-grade ocular adnexal lymphoma with localised radiotherapy to a median dose of 30 Gy in 15 fractions over 3 weeks.

Changes in corneal astigmatism among patients with visually significant cataract

OBJECTIVE

To determine the prevalence of corneal astigmatism, changes in astigmatism, and biometry measurements with age and to correlate fellow eye measurements of patients undergoing cataract surgery.

DESIGN

Prospective, observational study.

PARTICIPANTS

3498 eyes of 1814 patients undergoing cataract surgery.

METHODS

Setting was a single center teaching hospital. Preoperative biometry data measured by partial coherence interferometry (IOLMaster; Carl Zeiss Meditec, Jena, Germany) were collected and analyzed.

RESULTS

Mean age of the cohort was 74.52 ± 10.23 years. Mean corneal astigmatism was 1.04 ± 0.78 D OD and 1.04 ± 0.79 D OS. About 19.7% and 4.9% of eyes had corneal astigmatism greater than 1.5 and 2.5 D, respectively. The prevalence of against-the-rule astigmatism significantly increased with age bilaterally. Paired fellow eye analysis found a positive correlation for corneal astigmatism, axial length, anterior chamber depth, and white-to-white distance (p < 0.001). About 33.33% of right eyes with corneal astigmatism greater than 2.5 D had more than 2.5 D of astigmatism in the fellow eye. This is in comparison with only 1.5% of right eyes with corneal astigmatism of less than 1.5 D having corneal astigmatism greater than 2.5 D in the fellow eye.

CONCLUSIONS

Patients with high corneal astigmatism in 1 eye are more likely to have significant astigmatism in the fellow eye. This may necessitate the need for bilateral toric intraocular lens (IOL) implantation during cataract surgery. Against-the-rule astigmatism should be treated more aggressively during cataract surgery, because this is likely to worsen with age. Such information is useful when calculating toric IOL power at the time of surgery.

Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis

PURPOSE

Glaucoma is the leading cause of global irreversible blindness. Present estimates of global glaucoma prevalence are not up-to-date and focused mainly on European ancestry populations. We systematically examined the global prevalence of primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG), and projected the number of affected people in 2020 and 2040.

DESIGN

Systematic review and meta-analysis.

PARTICIPANTS

Data from 50 population-based studies (3770 POAG cases among 140,496 examined individuals and 786 PACG cases among 112 398 examined individuals).

METHODS

We searched PubMed, Medline, and Web of Science for population-based studies of glaucoma prevalence published up to March 25, 2013. Hierarchical Bayesian approach was used to estimate the pooled glaucoma prevalence of the population aged 40-80 years along with 95% credible intervals (CrIs). Projections of glaucoma were estimated based on the United Nations World Population Prospects. Bayesian meta-regression models were performed to assess the association between the prevalence of POAG and the relevant factors.

MAIN OUTCOME MEASURES

Prevalence and projection numbers of glaucoma cases.

RESULTS

The global prevalence of glaucoma for population aged 40-80 years is 3.54% (95% CrI, 2.09-5.82). The prevalence of POAG is highest in Africa (4.20%; 95% CrI, 2.08-7.35), and the prevalence of PACG is highest in Asia (1.09%; 95% CrI, 0.43-2.32). In 2013, the number of people (aged 40-80 years) with glaucoma worldwide was estimated to be 64.3 million, increasing to 76.0 million in 2020 and 111.8 million in 2040. In the Bayesian meta-regression model, men were more likely to have POAG than women (odds ratio [OR], 1.36; 95% CrI, 1.23-1.52), and after adjusting for age, gender, habitation type, response rate, and year of study, people of African ancestry were more likely to have POAG than people of European ancestry (OR, 2.80; 95% CrI, 1.83-4.06), and people living in urban areas were more likely to have POAG than those in rural areas (OR, 1.58; 95% CrI, 1.19-2.04).

CONCLUSIONS

The number of people with glaucoma worldwide will increase to 111.8 million in 2040, disproportionally affecting people residing in Asia and Africa. These estimates are important in guiding the designs of glaucoma screening, treatment, and related public health strategies.

Primary open-angle glaucoma in a population associated with high prevalence of primary angle-closure glaucoma: the Kumejima Study

PURPOSE

To evaluate the prevalence of and risk factors for primary open-angle glaucoma (POAG) in a rural population of southwestern Japan.

DESIGN

Population-based cross-sectional study.

PARTICIPANTS

All residents 40 years of age and older in Kumejima, Okinawa, Japan.

METHODS

Of the eligible 4632 residents 40 years of age and older, 3762 subjects (participant rate, 81.2%) underwent screening examinations, including visual acuity (VA) measurement, slit-lamp examination, Goldmann applanation tonometry, gonioscopy, undilated stereoscopic fundus photographs, autorefractometry, noncontact specular microscopy, pachymetry, and visual field (VF) testing using frequency-doubling technology. If glaucoma or other related ocular disorders were suspected, subjects were referred for definitive examinations including VF testing with the Humphrey Field Analyzer. The diagnosis of POAG was based on the criteria of the International Society for Geographical and Epidemiological Ophthalmology.

MAIN OUTCOME MEASURES

Prevalence and risk factors of POAG.

RESULTS

The prevalence of POAG was 4.0% (95% confidence interval [CI], 3.4%-4.7%); 82% of patients had an intraocular pressure (IOP) less than 22 mmHg, resulting in a prevalence of 3.3% (95% CI, 2.8%-3.9%). Because of POAG, 3 subjects had a VA worse than 20/400 in only 1 eye, and 1 subject had VA loss of worse than 20/400 bilaterally. The average IOP values (mean ± standard deviation) were 14.9 ± 3.2 and 14.6 ± 3.3 mmHg in the right and left eyes, respectively; the IOP values were higher in patients with POAG (15.4 ± 3.3 and 15.2 ± 3.3 mmHg, respectively) than in subjects without glaucoma (14.8 ± 3.1 and 14.4 ± 3.1 mmHg, respectively; P<0.045, Student t test). Multivariate analysis showed that male gender (P = 0.003), older age (P<0.001), higher IOP (P<0.001), longer axial length (P<0.001), and thinner central cornea (P = 0.006) were associated with POAG.

CONCLUSIONS

High prevalence rates of POAG (4.0%) and POAG with normal IOP levels (3.3%), which were comparable with those on the Japanese mainland, were found in a southwestern rural island of Japan, where the prevalence of primary angle-closure glaucoma (previously reported as 2.2%) was considerably higher than on the Japanese mainland (0.6% in the Tajimi Study) or other countries. The risk factors for POAG included male gender, older age, higher IOP, myopia, and a thinner cornea.

Risk factors for depressed mood amongst a community dwelling older age population in England: cross-sectional survey data from the PRO-AGE study

BACKGROUND

The Quality and Outcomes Framework in the United Kingdom (UK) National Health Service previously highlighted case finding of depression amongst patients with diabetes or coronary heart disease. However, depression in older people remains under-recognized. Comprehensive data for analyses of the association of depression in older age with other health and functional measures, and demographic factors from community populations within England, are lacking.

METHODS

Secondary analyses of cross-sectional baseline survey data from the England arm of a randomised controlled trial of health risk appraisal for older people in Europe; PRO-AGE study. Data from 1085 community-dwelling non-disabled people aged 65 years or more from three group practices in suburban London contributed to this study. Depressed mood was ascertained from the 5-item Mental Health Inventory Screening test. Exploratory multivariable logistic regression was used to identify the strongest associations of depressed mood with a previous diagnosis of a specified physical/mental health condition, health and functional measures, and demographic factors.

RESULTS

Depressed mood occurred in 14% (155/1085) of participants. A previous diagnoses of depression (OR 3.39; P < 0.001) and poor vision as determined from a Visual Function Questionnaire (OR 2.37; P = 0.001) were amongst the strongest factors associated with depressed mood that were independent of functional impairment, other co-morbidities, and demographic factors. A subgroup analyses on those without a previous diagnosis of depression also indicated that within this group, poor vision (OR 2.51; P = 0.002) was amongst the strongest independent factors associated with depressed mood.

CONCLUSIONS

Previous case-finding strategies in primary care focussed on heart disease and diabetes but health-related conditions other than coronary heart disease and diabetes are also associated with an increased risk for depression. Complex issues of multi-morbidity occur within aging populations. 'Risk' factors that appeared stronger than those, such as, diabetes and coronary heart disease that until recently prompted for screening in the UK due to the QOF, were identified, and independent of other morbidities associated with depressed mood. From the health and functional factors investigated, amongst the strongest factors associated with depressed mood was poor vision. Consideration to case finding for depressed mood among older people with visual impairment might be justified.

The British Asian community eye study: outline of results on the prevalence of eye disease in British Asians with origins from the Indian subcontinent

Background:

Asians from the Indian Subcontinent form the largest ethnic minority in the United Kingdom. Data on the prevalence of visually-impairing eye conditions in this population are vital for planning eye health care services.

Materials and Methods:

This survey was based in the two London boroughs with the largest Asian populations. Subjects originating from the Indian Subcontinent were identified from GP practice records. All subjects were asked about demographic details and were given a full ophthalmological examination. The severity of cataract, glaucoma, diabetic retinopathy, and age-related maculopathy was recorded. Blindness was defined as logMAR visual acuity of 0.99 (Snellen equivalence 20/200 in the better eye) or worse, ‘low vision’ was defined as Snellen equivalence of 20/63 or worse (logMAR 0.5 or higher), and visual impairment was defined as visual acuity worse than 20/40.

Results:

The median age was 56 years. Two hundred and eighty four subjects did not attend for eye examination. Of the 922 examined, 128 subjects (13.9%) were ‘visually impaired,’ 39 (4.2%) had ‘low vision,’ and 6 (0.7%) were bilaterally blind. The overall prevalence of cataract, open-angle glaucoma, age-related macular degeneration, and diabetic retinopathy were 77%, 1.0%, 8.7%, and 8.8%, respectively.

Conclusion:

Visual impairment rates amongst Asians seem to be similar to Caucasian populations in the UK. The prevalence of cataract and diabetic retinopathy is higher, while the risk of ARMD and OAG are comparable. In view of the high cataract prevalence, a more detailed assessment of the visual profile and factors limiting healthcare accessibility in this community are needed.

Health risk appraisal in older people 6: factors associated with self-reported poor vision and uptake of eye tests in older people

BACKGROUND

Although free eye testing is available in the UK from a nation-wide network of optometrists, there is evidence of unrecognised, tractable vision loss amongst older people. A recent review identified this unmet need as a priority for further investigation, highlighting the need to understand public perceptions of eye services and barriers to service access and utilisation. This paper aims to identify risk factors for (1) having poor vision and (2) not having had an eyesight check among community-dwelling older people without an established ophthalmological diagnosis.

METHODS

Secondary analysis of self-reported data from the ProAge trial. 1792 people without a known ophthalmological diagnosis were recruited from three group practices in London.

RESULTS

Almost two in ten people in this population of older individuals without known ophthalmological diagnoses had self-reported vision loss, and more than a third of them had not had an eye test in the previous twelve months. In this sample, those with limited education, depressed mood, need for help with instrumental and basic activities of daily living (IADLs and BADLs), and subjective memory complaints were at increased risk of fair or poor self-reported vision. Individuals with basic education only were at increased risk for not having had an eye test in the previous 12 months (OR 1.52, 95% CI 1.17-1.98 p=0.002), as were those with no, or only one chronic condition (OR 1.850, 95% CI 1.382-2.477, p<0.001).

CONCLUSIONS

Self-reported poor vision in older people without ophthalmological diagnoses is associated with other functional losses, with no or only one chronic condition, and with depression. This pattern of disorders may be the basis for case finding in general practice. Low educational attainment is an independent determinant of not having had eye tests, as well as a factor associated with undiagnosed vision loss. There are other factors, not identified in this study, which determine uptake of eye testing in those with self-reported vision loss. Further exploration is needed to identify these factors and lead towards effective case finding.

Comparison of resource utilization in the treatment of open-angle glaucoma between two cities in Finland: is more better?

INTRODUCTION

Glaucoma is a progressive optic neuropathy associated with neural rim loss of the optic disc and the retinal nerve fibre layer typically causing visual field (VF) deterioration. Generally, glaucomatous lesions in the eye and in the visual field progress slowly over the years. In population-based cross-sectional studies, the percentage of unilateral or bilateral visual impairment varied between 3-12%. In screening studies, 0.03-2.4% of patients have been found to suffer visual impairment. Glaucoma has previously been associated with substantial healthcare costs and resource consumption attributable to the treatment of the disease. The disease also causes reduction in health-related quality of life (HRQoL) in patients with glaucoma.

OBJECTIVE AND METHODS

This study compares patients with diagnosed open-angle glaucoma from two geographically different regions in Finland. A total of 168 patients were examined, 85 subjects from an area with higher per patient treatment costs (Oulu) and 83 patients from a region with lower per patient treatment costs (Turku). All patients had a history of continuous glaucoma medication use for a period of 11 years. For each patient, the total direct costs from glaucoma treatment were calculated and the total amount of resource consumption was determined from registries and patient records. Each patient underwent a clinical examination with visual field assessment and fundus photography. These data were used to determine the current stage of disease for each patient. Health-related quality of life questionnaire (15D) was used in determining each patient's subjective HRQoL score.

RESULTS

When applying the current diagnostic criteria for open-angle glaucoma, a total of 40% of patients did not to display any structural or functional damage suggesting glaucoma after 11 years of continuous medical treatment and follow-up. Patients with higher glaucoma stage (worse disease) were found to have statistically higher treatment costs compared with those at lower disease stages. Resource consumption was also greater in the patients in higher glaucoma stage. Patients in the Oulu district consumed more resources, and glaucoma treatment was more expensive than in the Turku area. The total treatment cost in Oulu and Turku was 6010 € and 4452 €, respectively, for the whole 11-year period. There was no statistically significant difference in quality-of-life scores between the two areas. No difference was noted between the higher-spending and lower-spending areas in this respect. However, when the population was analysed as a whole, patients with higher glaucoma stage were found to have lower vision-based 15D scores compared with those at lower disease stages. This observation was made also at both districts independently.

CONCLUSIONS

Major cost source in open-angle glaucoma treatment is medication, up to 74% of annual costs. In addition, it seems that higher resource consumption and higher treatment costs do not increase the patients' HRQoL as assessed by the 15D instrument.

Interventions for improving adherence to ocular hypotensive therapy

BACKGROUND

Poor adherence to therapy is a significant healthcare issue, particularly in patients with chronic disease such as open-angle glaucoma. Treatment failure may necessitate unwarranted changes of medications, increased healthcare expenditure and risk to the patient if surgical intervention is required. Simplifying eye drop regimes, providing adequate information, teaching drop instillation technique and ongoing support according to the patient need may have a positive effect on improving adherence.

OBJECTIVES

To summarise the effects of interventions for improving adherence to ocular hypotensive therapy in people with ocular hypertension (OHT) or glaucoma.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 6), MEDLINE (June 1946 to June 2012), EMBASE (June 1980 to June 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (June 1937 to June 2012), PsycINFO (1806 to June 2012), PsycEXTRA (1908 to June 2012), Web of Science (1970 to June 2012), ZETOC (1993 to June 2012), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 June 2012. We did not search the National Research Register (NNR) as this resource has now been now archived. We contacted pharmaceutical manufacturers to request unpublished data and searched conference proceedings for the Association for Research in Vision and Ophthalmology (ARVO), and the Annual Congress for the Royal College of Ophthalmologists (RCO).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared interventions to improve adherence to ocular hypotensive therapy for patients with OHT or glaucoma.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed the search results for eligibility and extracted data for included trials onto specifically designed forms. We did not pool data due to clinical and methodological heterogeneity.

MAIN RESULTS

Sixteen trials (1565 participants) met the inclusion criteria. Seven studies investigated some form of patient education. In six of these studies this education was combined with other behavioural change interventions including tailoring daily routines to promote adherence to eye drops. Eight studies compared different drug regimens (one of these trials also compared open and masked monitoring) and one study investigated a reminder device. The studies were of variable quality and some were at considerable risk of bias; in general, the length of follow-up was short at less than six months with only two studies following up to 12 months. Different interventions and outcomes were reported and so it was not possible to produce an overall estimate of effect. There was some evidence from three studies that education combined with personalised interventions, that is, more complex interventions, improved adherence to ocular hypotensive therapy. There was less information on other outcomes such as persistence and intraocular pressure, and no information on visual field defects, quality of life and cost. There was weak evidence as to whether people on simpler drug regimens were more likely to adhere and persist with their ocular hypotensive therapy. A particular problem was the interpretation of cross-over studies, which in general were not reported correctly. One study investigated a reminder device and monitoring but the study was small and inconclusive.

AUTHORS' CONCLUSIONS

Although complex interventions consisting of patient education combined with personalised behavioural change interventions, including tailoring daily routines to promote adherence to eye drops, may improve adherence to glaucoma medication, overall there is insufficient evidence to recommend a particular intervention. The interventions varied between studies and none of the included studies reported on the cost of the intervention. Simplified drug regimens also could be of benefit but again the current published studies do not provide conclusive evidence. Future studies should follow up for at least one year, and could benefit from standardised outcomes.

Socioeconomic disparities in cataract surgery

PURPOSE OF REVIEW

As the elderly population continues to grow in the USA, an understanding of the increasing burden of cataract is pivotal. This review seeks to iterate the presence of this burden and to understand it better in the context of race, sex, and socioeconomic factors.

RECENT FINDINGS

Although there have been multiple prevalence studies addressing the cataract burden in the USA, updated literature that directly elucidates the above issues has been sparse. Recent data support previous findings that the cataract burden among women is greater than that of men, likely predominantly due to greater longevity. With regard to race, there appears to be a slightly increased burden among Whites, although this increase may show regional variability and change over the next few decades, especially as the presently young Hispanic population continues to age and grow. It is likely that the significant divider responsible for unmet cataract surgery is socioeconomic, due to such factors as insurance coverage, income, and barriers to access such as transportation, service accessibility, and awareness. These latter barriers of income and access appear to be identical to those identified in developing countries.

SUMMARY

The cataract burden in the USA is significant and is expected to continue to grow. Further studies are warranted to help us better understand barriers to access, particularly with regard to race and socioeconomic factors. Local efforts to address education and logistical barriers as well as nationwide policy efforts to address insurance coverage appear to be a crucial factor in surmounting an ongoing but treatable chronic disease.

The EPIC-Norfolk Eye Study: rationale, methods and a cross-sectional analysis of visual impairment in a population-based cohort

OBJECTIVES

To summarise the methods of the European Prospective Investigation of Cancer (EPIC)-Norfolk Eye Study, and to present data on the prevalence of visual impairment and associations with visual impairment in the participants.

DESIGN

A population-based cross-sectional study nested within an on-going prospective cohort study (EPIC).

SETTING

East England population (the city of Norwich and its surrounding small towns and rural areas).

PARTICIPANTS

A total of 8623 participants aged 48-92 years attended the Eye Study and underwent assessment of visual acuity, autorefraction, biometry, tonometry, corneal biomechanical measures, scanning laser polarimetry, confocal scanning laser ophthalmoscopy, fundal photography and automated perimetry.

OUTCOME MEASURES

Visual impairment was defined according to the WHO classification and the UK driving standard, and was based on presenting visual acuity. Summary measures of other ophthalmic measurements are also presented.

RESULTS

The prevalence (95% CI) of WHO-defined moderate-to-severe visual impairment and blindness was 0.74% (0.55% to 0.92%). The prevalence (95% CI) of presenting visual acuity worse than the UK driving standard was 5.87% (5.38% to 6.37%). Older age was significantly associated with visual impairment or blindness (p<0.001). Presenting visual acuity worse than UK driving standard was associated with older age (p<0.001), female sex (p=0.005) and lower educational level (p=0.022).

CONCLUSIONS

The prevalence of blindness and visual impairment in this selected population was low. Visual impairment was more likely in older participants, women and those with a lower educational level.

Glaucoma diagnostics

This thesis addresses several aspects of glaucoma diagnostics from both a clinical and a screening perspective. New instruments for diagnosing glaucoma have been developed over the past years, but little information is available regarding their performance as screening methods and their usefulness in ordinary clinical practice. PURPOSE OF THE RESEARCH UNDERLYING THIS THESIS:  The objectives of this research were as follows: to compare the accuracy of results of analysis of the optic nerve head (ONH) achieved by computerized imaging using the Heidelberg Retina Tomograph (HRT) and by subjective assessment performed by physicians with different degrees of experience of glaucoma (paper III); to evaluate the effect of a continuous medical education (CME) lecture on subjective assessment of the ONH for diagnosis of glaucoma (paper II); to investigate subjective assessment of perimetric test results by physicians with varying knowledge of glaucoma with a trained artificial neural network (ANN) and to compare the certainty of the classifications (paper IV); and to compare the diagnostic performance of time-domain Stratus optical coherence tomography (OCT) with that of spectral-domain Cirrus OCT (paper I), frequency doubling technology (FDT) screening perimetry and scanning laser polarimetry with the GDx variable corneal compensator (VCC) in a random population-based sample and in patients with glaucoma of varying disease severity.

METHODS AND RESULTS

  In evaluation of the ONH, use of the HRT statistical tools, Moorfields regression analysis (MRA) and the Glaucoma Probability Score (GPS) was compared with subjective assessment performed by 45 physicians. Optic nerve head images and photographs from 138 healthy and 97 glaucoma subjects were included. The sensitivity of MRA was higher (87-94%) than that of the average physician (62-82%), considerably greater than that of ophthalmologists with subspecialties other than glaucoma (53-77%) and non-significantly better than that of glaucoma experts (72-88%). Sensitivity achieved by GPS (79-93%) was also greater than that of the average physician. MRA correctly classified all eyes with advanced glaucomatous visual field defects, a result that was not achieved by GPS or even by the glaucoma experts. In eyes with small discs, MRA sensitivity (88%) was comparable with that of glaucoma experts (85%) and much better than that of GPS (50%). Also, the group comprising all physicians provided specificity (75-92%) similar to that of both MRA (69 - 86%) and GPS (72-94%) (Andersson et al. 2011a). A 1-hr CME lecture on ONH assessment led to a significant improvement in sensitivity (from 70% to 80%) and a significant decrease in uncertain assessments (from 22% to 13%), whereas specificity remained unchanged (68%) (Andersson et al. 2011b). A rise in sensitivity was seen in all subgroups of physicians, including glaucoma experts. Thirty physicians assessing standard automated perimetry (SAP) test results as Humphrey Field Analyzer single-field analysis printouts with full StatPac information from 99 patients with glaucoma and 66 healthy subjects were compared with a trained ANN regarding diagnostic performance. ANN reached significantly higher sensitivity (93%) than the average physician (83%), whereas specificity was similar for these two groups (91% and 90%, respectively). Diagnostic accuracy was similar among the different groups of physicians and seemingly rather independent of experience. Sensitivity ranged from 82% in the subgroup of other subspecialists to 87% in the glaucoma expert group, and specificity ranged from 88% among general ophthalmologists to 91% for glaucoma experts. The ANN attained certainty of classification that was in parity with that provided by the glaucoma experts and did not make any completely incorrect classifications of the visual fields (i.e. erroneous classifications were in the borderline zone) (Andersson et al. 2012). From a population-based randomly selected sample (n=308) of older subjects (aged ≥ 50 years) living in southern Sweden, 170 subjects underwent a comprehensive examination that included Stratus OCT, Cirrus OCT, an FDT screening programme and the GDx VCC. The same test protocol was applied to 138 randomized clinical patients with different stages of glaucoma. In the population-based sample, both Stratus and Cirrus OCT showed high diagnostic accuracy with area under the receiver-operating curve (aROC) values close to 1.0 (Bengtsson et al. 2012). Both OCT instruments correctly classified all of the clinical glaucoma patients with advanced disease. FDT screening showed high sensitivity (91%) but erroneously gave normal test results for some eyes with advanced disease. GDx VCC had lower sensitivity (73-92%) and also led to a large proportion of examinations with an atypical retardation pattern that is known to affect the diagnostic efficiency of this instrument.

CONCLUSIONS

  The HRT MRA performed better than most physicians and was consistent with the glaucoma experts. These results suggest that MRA can be a valuable tool for diagnosing glaucoma in ordinary practice, particularly when only a few glaucoma experts are available. Even though MRA provided 100% sensitivity in eyes with advanced glaucoma, it probably does not offer sufficient specificity to make it suitable as a screening method. Continuing medical education on ONH analysis had a small, but positive effect on diagnostic accuracy for glaucoma. An ANN trained to classify visual fields seemed to perform at least as well as most of the participating physicians, whose performances were remarkably similar regardless of their level of experience. This indicates that available tools for interpreting SAP findings are helpful in assessments of visual field test results. However, SAP is associated with learning effects (Heijl et al. 1989) that may entail low specificity for untrained subjects, and hence, it is not an ideal screening method for glaucoma. By comparison, the screening test of FDT is rapid and easy, but it is probably less suitable for screening purpose, because some eyes with advanced glaucoma were missed in this investigation. GDx VCC images for a relatively large number of eyes could not be analysed and is thus not appropriate for screening. The OCT instruments offer both high sensitivity and high specificity, and all eyes with advanced disease were correctly classified as glaucomatous in this evaluation. However, these instruments are still expensive and require special operator skills. Additional development to obtain OCT instrument that is more compact, easier to use and less expensive might render such tomography suitable as a screening tool for glaucoma.

A randomized, single-center study of equivalence of 2 intraocular lenses used in cataract surgery

PURPOSE

To compare the outcomes of 2 intraocular lenses (IOLs) for the treatment of age-related cataracts.

DESIGN

Prospective, randomized trial.

PARTICIPANTS

Patients with age-related cataracts were recruited and randomized to receive phacoemulsification and implantation of either the AcrySof SA60AT lens (Alcon, Inc, Fort Worth, TX) or the low-cost Tecsoft Flex lens (Fred Hollows Foundation, Tilganga, Nepal). A total of 300 patients were available for description and analysis (148 in the AcrySof group and 152 in the Tecsoft group).

METHODS

Patients underwent phacoemulsification and implantation of the AcrySof SA60AT lens or the Tecsoft Flex lens. They were followed up and examined at baseline, 1 week, 1 month, 6 months, and 12 months after cataract surgery.

MAIN OUTCOME MEASURES

Uncorrected distance visual acuity (UDVA), best-corrected distance visual acuity (BDVA), incidence of posterior capsule opacification (PCO), Visual Function Index questionnaire results, and safety of the implanted IOLs.

RESULTS

No significant difference (P>0.05) was found in UDVA and BDVA after surgery between the 2 groups. The equivalence test of the 95% confidence intervals showed that both lenses had an equal improvement of UDVA and BDVA as well as similar rates of PCO after cataract surgery. There was no significant difference between the 2 groups with regard to visual functioning or the incidence of adverse surgical events during (P>0.05) or after (P>0.05) the surgery.

CONCLUSIONS

The Tecsoft Flex IOL is a low-cost suitable alternative that is similar to the AcrySof IOL in terms of safety and visual outcomes.

Access to eye health services among indigenous Australians: an area level analysis

BACKGROUND

This project is a community-level study of equity of access to eye health services for Indigenous Australians.

METHODS

The project used data on eye health services from multiple sources including Medicare Australia, inpatient and outpatient data and the National Indigenous Eye Health Survey.The analysis focused on the extent to which access to eye health services varied at an area level according to the proportion of the population that was Indigenous (very low = 0-1.0%, low = 1.1-3.0%, low medium = 3.1-6.0%, high medium = 6.1-10.0%, high = 10.1-20.0%, very high = 20 + %). The analysis of health service utilisation also took into account age, remoteness and the Socioeconomic Indices for Areas (SEIFA).

RESULTS

The rate of eye exams provided in areas with very high Indigenous populations was two-thirds of the rate of eye exams for areas with very low indigenous populations. The cataract surgery rates in areas with high medium to very high Indigenous populations were less than half that reference areas. In over a third of communities with very high Indigenous populations the cataract surgery rate fell below the World Health Organization (WHO) guidelines compared to a cataract surgery rate of 3% in areas with very low Indigenous populations.

CONCLUSIONS

There remain serious disparities in access to eye health service in areas with high Indigenous populations. Addressing disparities requires a co-ordinated approach to improving Indigenous people's access to eye health services. More extensive take-up of existing Medicare provisions is an important step in this process. Along with improving access to health services, community education concerning the importance of eye health and the effectiveness of treatment might reduce reluctance to seek help.

Visual acuity improvements after implantation of toric intraocular lenses in cataract patients with astigmatism: a systematic review

Background

Cataracts are a common and significant cause of visual impairment globally. We aimed to evaluate uncorrected distance visual acuity (UDVA) as an outcome in treating astigmatic cataract patients to assist clinicians or ophthalmologists in their decision making process regarding available interventions.

Methods

Medline, Embase and Evidence Based Reviews were systematically reviewed to identify relevant studies reporting changes in UDVA, UIVA and UNVA after cataract surgery in presbyopic patients. Strict inclusion/exclusion criteria were used to exclude any non-relevant studies. Relevant outcomes (UDVA, UIVA and UNVA) were identified from the studies retrieved through the systematic review process.

Results

The systematic review identified 11 studies which reported UCVA. All 11 studies reported UDVA. Four brands of toric intraocular lenses (IOLs) were reported in these studies. All studies identified in the literature search reported improvements in UDVA following surgical implant of a toric IOL. The largest improvements in VA were reported using the Human Optics MicroSil toric IOL (0.74 LogMAR, UDVA) and the smallest improvements were also reported using the Human Optics MicroSil toric IOL (0.23 LogMAR, UDVA) in a different study.

Conclusions

The results of this systematic review showed the aggregate of studies reporting a beneficial increase in UDVA with the use of toric IOLs in cataract patients with astigmatism.

Time Required for Screening for Visual Impairment in Primary Care

Objective: To determine the time required for adults older than 50 years to complete 1 of 3 vision impairment assessment tools in a family medicine residency office. Methods: Patients older than 50 years with no known cognitive or physical deficits that impaired ability to follow directions or complete screening tasks were invited to participate in this trial. Participants were randomized to complete 1 of 3 screening modalities, namely, the Functional Vision Screening Questionnaire (questionnaire), mixed contrast sensitivity reading card (card), or Snellen eye chart (Snellen). The time required to complete the vision assessment was obtained and recorded. Results: Sixty-nine patients, with a mean age of 63 years (SD, 10), participated in the study. The card required 94 less seconds to administer than did the questionnaire (95% confidence interval, 61.24 to 127.11 seconds). Similarly, the card required 67 less seconds to administer than did the Snellen (95% confidence interval, 34.20 to 100.06 seconds). No significant difference existed between time to administer the questionnaire and the Snellen (mean difference, 27 seconds; 95% confidence interval, –5.89 to 59.97 seconds). Conclusions: Primary care–based vision screening may detect patients with impairment who would otherwise not have vision assessment. However, a time-intensive screen will not likely be successfully implemented in a primary care office. The card required statistically significantly less time to administer than did the questionnaire or Snellen. With all modalities requiring at least 1 minute, perhaps none are suitable for use for universal, primary care–based vision screening programs. Further work is needed to characterize the reliability and ease of use of each tool.

Uncorrected refractive error in older British adults: the EPIC-Norfolk Eye Study

AIM

To investigate the prevalence of, and demographic associations with, uncorrected refractive error (URE) in an older British population.

METHODS

Data from 4428 participants, aged 48-89 years, who attended an eye examination in the third health check of the European Prospective Investigation into Cancer-Norfolk study and had also undergone an ophthalmic examination were assessed. URE was defined as ≥1 line improvement of visual acuity with pinhole-correction in the better eye in participants with LogMar presenting visual acuity (PVA) <0.3 (PVA <6/12). Refractive error was measured using an autorefractor without cycloplegia. Myopia was defined as spherical equivalent ≤-0.5 dioptre, and hypermetropia ≥0.5 dioptre.

RESULTS

Adjusted to the 2010 midyear British population, the prevalence of URE in this Norfolk population was 1.9% (95% CI 0.6% to 3.1%). Lower self-rated distance vision was correlated with higher prevalence of URE (p(trend)<0.001). In a multivariate logistic regression model adjusting for age, gender, retirement status, educational level and social class, independent significant associations with URE were increasing age (p(trend)<0.001) and having hypermetropic or myopic refractive error. Wearing distance spectacles was inversely associated with URE (OR 0.34, 95% CI 0.21 to 0.55, p<0.001). There were 3063 people (69.2%) who wore spectacles/contact lenses for distance vision. Spectacle wear differed according to type of refractive error (p<0.001), and use rose with increasing severity of refractive error (p(trend)<0.001).

CONCLUSION

Although refractive error is common, the prevalence of URE was found to be low in this population reflecting a low prevalence of PVA<0.3.