The ARMS2 A69S Polymorphism Is Associated with Delayed Rod-Mediated Dark Adaptation in Eyes at Risk for Incident Age-Related Macular Degeneration.

PURPOSE: To examine the association between sequence variants in genetic risk factors for age-related macular degeneration (AMD) and delayed rod-mediated dark adaptation (RMDA), the first functional biomarker for incident AMD, in older adults with normal macular health and early AMD. DESIGN: Cross-sectional. PARTICIPANTS: Adults 60 years of age or older showing normal macular health (defined as both eyes at step 1 on the Age-Related Eye Disease Study 9-step AMD classification system) and those with AMD in one or both eyes (defined as steps 2-9). METHODS: Single nucleotide polymorphisms were genotyped in the complement factor H (CFH) and ARMS2 genes using a Taqman assay. Rod-mediated dark adaptation was assessed in 1 eye after photobleach with targets centered at 5° on the inferior vertical meridian. Rate of dark adaptation was defined by rod intercept time (RIT), duration (in minutes) required for sensitivity to reach a criterion sensitivity level in the latter half of the second component of rod recovery. Associations between CFH and ARMS2 polymorphisms and RMDA were adjusted for age and smoking. MAIN OUTCOME MEASURE: Rod intercept time. RESULTS: The sample consisted of 543 participants having both genotype and RIT determination; 408 showed normal macular health and 135 demonstrated AMD, most having early AMD (124 of 135). For the combined sample, higher RIT (slower RMDA) was observed for both the A69S variant in ARMS2 and the Y402H variant in CFH (adjusted P = 0.0001 and P = 0.0023, respectively). For healthy participants, the A69S variant in ARMS2 was associated with higher RIT (adjusted P = 0.0011), whereas the Y402H variant in CFH was not (adjusted P = 0.2175). For AMD patients, the A69S variant of ARMS2 and the Y402H variant of CFH were associated with higher RIT (adjusted P = 0.0182 and P = 0.0222, respectively). Those with a larger number of high-risk ARMS2 and CFH alleles showed higher RIT, in both healthy and AMD groups (adjusted P = 0.0002 and P < 0.0001, respectively). CONCLUSIONS: We report a novel association wherein older adults with high-risk ARMS2 and CFH genotypes are more likely to demonstrate delayed RMDA, the first functional biomarker for incident early AMD. Before the AMD clinical phenotype is present, those showing normal macular health with the ARMS2 A69S allele demonstrate delayed RMDA. Understanding ARMS2 function is a research priority.

A survey of Alabama eye care providers in 2010-2011.

BACKGROUND: State level information regarding eye care resources can provide policy makers with valuable information about availability of eye care services. The current study surveyed ophthalmologists, optometrists and vision rehabilitation providers practicing in Alabama. METHODS: Three mutually exclusive provider groups were identified, i.e., all ophthalmologists, optometrists, and vision rehabilitation providers working in Alabama in 2010. Eligible providers were contacted in 2010 and 2011 and information was requested regarding provider demographics and training, practice type and service characteristics, and patient characteristics. Descriptive statistics (e.g., means, proportions) were used to characterize provider groups by their demographic and training characteristics, practice characteristics, services provided and patients or clients served. In addition, county level figures demonstrate the numbers and per capita ophthalmologists and optometrists. RESULTS: Ophthalmologists were located in 24 of Alabama's 67 counties, optometrists in 56, and 10 counties had neither an ophthalmologist nor an optometrist. Overall, 1,033 vision care professionals were identified as eligible to participate in the survey: 217 ophthalmologists, 638 optometrists, and 178 visual rehabilitation providers. Of those, 111 (51.2%) ophthalmologists, 246 (38.6%) optometrists, and 81 (45.5%) rehabilitation providers participated. Most participating ophthalmologists, optometrists, and vision rehabilitation providers identified themselves as non-Hispanic White. Ophthalmologists and optometrists estimated that 27% and 22%, respectively, of their patients had diabetes but that the proportion that adhered to eye care guidelines was 61% among ophthalmology patients and 53% among optometry patients. CONCLUSIONS: A large number of Alabama communities are isolated from eye care services. Increased future demand for eye care is anticipated nationally given the aging of the population and decreasing numbers of providers; however, Alabama also has a high and growing prevalence of diabetes which will result in greater numbers at risk for diabetic retinopathy, glaucoma, and cataracts.

Effect of an eye health education program on older African Americans' eye care utilization and attitudes about eye care.

UNLABELLED: We examined the impact of an eye health education program for older African Americans on attitudes about eye care and utilization, using a randomized trial design in a community setting. Participants were older African Americans attending activities at senior centers: Ten centers were randomized to an eye health education (InCHARGE) or social-contact control presentation. InCHARGE addressed the importance of annual dilated comprehensive examination and strategies reducing barriers to care. The control presentation was on the importance of physical activity. Outcomes were attitudes about eye care 6 months post event through questionnaire and eye care utilization during 12 months post event through medical record abstraction. At baseline, more than 80% participants in both arms said transportation and finding, communicating, and trusting a doctor were not problematic and agreed that yearly care was important. One-fourth said eye examination cost was problematic; one-half said spectacle cost was problematic. There were no group differences 6 months post event. During the 12 months pre event, the dilated exam rate was similar in the groups (38.3% InCHARGE, 40.8% control) and unchanged during the 12 moiths post event. Results suggest fewer than half of older African Americans received annual dilated eye care. Group-administered eye health education did not increase this rate. Even before the program, they had positive attitudes about care, yet many cited examination and spectacle cost as problematic, which was not mitigated by health education. Evidence-based strategies in a community setting for increasing eye care utilization rate in older African Americans have yet to be identified. Policy changes may be more appropriate avenues for addressing cost. TRIAL REGISTRATION: NCT00591110, www.ClinicalTrials.gov

Use of prescribed optical devices in age-related macular degeneration.

PURPOSE: To evaluate prescribed optical device use in terms of frequency and perceived usefulness among people with age-related macular degeneration (AMD). We also sought to determine the tasks for which they were using their prescribed low vision device(s). METHODS: One hundred ninety-nine patients with AMD presenting for the first time to the low vision service were recruited from a university-based clinic. Prior to the low vision evaluation and device prescription, they completed the National Eye Institute Visual Function Questionnaire 25, Center for Epidemiological Studies Depression Scale, Short Portable Mental Status Questionnaire, and a general health questionnaire. The low vision evaluation included best-corrected Early Treatment of Diabetic Retinopathy Study visual acuity, MNREAD testing, microperimetry, prescription, and dispensing of optical low vision devices. Telephone follow-up interviews were conducted about device usage 1-week, 1-month, and 3-months postintervention. RESULTS: One hundred eighty-one participants were prescribed low vision devices. Of them, 93% completed all 3 follow-up interviews. Intensive users (≥1 hours/day) of devices were similar in demographic and visual characteristics to non-intensive users (<1 hours/day), except for habitual reading acuity and speed as well as contrast sensitivity. Overall, device use increased slightly over 3 months of follow-up. Magnifiers were reported to be moderately-to-extremely useful by >80% of participants at all time points except the 1-month follow-up for hand magnifiers (75%). High plus spectacles were the least frequently prescribed device and rated as moderately-to-extremely useful by 70%, 74%, and 59% at 1 week, 1 month, and 3 months, respectively. Most participants used their devices for leisure reading, followed by managing bills. Very few devices (n = 3, <1%) were not used at any time point. CONCLUSIONS: Patients with AMD who are provided with prescribed optical low vision devices do use them and perceive them as useful, especially for leisure reading activities. High rates of usage were maintained over 3 month.

Educating older African Americans about the preventive importance of routine comprehensive eye care.

Older African Americans have higher rates of vision impairment and lower utilization rates of comprehensive eye care, compared to Caucasians. InCHARGE is an eye health education program for this population that promotes prevention through the annual, dilated comprehensive eye examination. This study, using a pre-/postdesign, evaluated whether InCHARGE imparted knowledge about prevention and strategies for reducing barriers to care. The program was presented to 85 older African Americans in 5 senior centers in Montgomery, AL. Changes in attitudes about annual eye care were assessed by a questionnaire before and 3 months after InCHARGE. At baseline, most (> 85%) responded it would not be difficult for them to find an ophthalmologist or optometrist, and the exam cost was not a problem. Twenty-five percent reported problems finding transportation to the doctor and covering the eyeglasses cost. Forty-four percent reported not having an eye exam in the past year; 13% reported not having one within 2 years. Three months after InCHARGE, those who reported that they could find a way to get to the doctor increased (X2 = 3.8, p = 0.04). After InCHARGE, 72% said they either had received or scheduled an eye exam. Responses to a question about what was learned from InCHARGE indicated that the InCHARGE's key messages about comprehensive eye care were successfully imparted to most. This study suggests that older African Americans in the urban south have positive attitudes about eye care, even before an eye health education presentation. Following InCHARGE, they identified transportation problems less frequently as a barrier, indicated that they learned InCHARGE's key message and had plans for seeking routine, preventive eye care. A next step is to verify through medical record review the extent to which the high rates of self-reported eye care utilization reflect behavior.

Perceived barriers to care and attitudes about vision and eye care: focus groups with older African Americans and eye care providers.

PURPOSE: To identify by using focus group methods the perceived barriers to eye care and attitudes about vision and eye care among older African Americans as well as among ophthalmologists and optometrists serving their communities. METHODS: Seventeen focus groups of older African Americans residing in the Birmingham or Montgomery, Alabama, areas were led by an experienced facilitator. Discussion was stimulated by a semistructured script focused on their perceived barriers to eye care and attitudes about vision and eye care. Six focus groups of ophthalmologists and optometrists who practiced in this geographic region addressed the same topics. Discussion was audiotaped and transcribed. Comments were coded using a multistep content analysis protocol. RESULTS: One hundred nineteen African Americans (age range, 59-97 years) and 35 eye care providers (51% ophthalmologists, 49% optometrists) participated. The barrier-to-care problem most frequently cited by both African Americans and eye care providers was transportation. The next most common problems mentioned by African Americans were trusting the doctor, communicating with the doctor, and the cost of eye care; and for eye care providers, the next most common problems were cost, trust, and insurance. With respect to older African Americans' comments on their attitudes about vision and eye care, these comments were predominantly positive (69%), highlighting the importance of eye care and behavior in their lives and attitudes that facilitated care. However, when eye care providers relayed their impressions of African Americans' attitudes about vision and eye care, their comments were largely negative (74%) centering on concerns and frustrations that older African Americans did not have attitudes or engage in behavior that facilitate eye care. CONCLUSIONS: These results provide some guidance for the design of interventions to increase the use of routine eye care in this population. At a societal level, there is a need for affordable and accessible transportation services for older African Americans seeking eye care. For ophthalmologists, optometrists, and their staffs, there is a need for continuing education that imparts culturally sensitive and age-appropriate communication and trust-building skills for interactions with this population. In addition to reinforcing the generally positive attitudes of older African Americans toward the importance of eye care, community-based educational programs should be focused on strategies for overcoming the common barriers to care.

Health-related quality of life and psychosocial characteristics of patients with benign essential blepharospasm.

OBJECTIVE: To examine vision-targeted health-related quality of life and psychosocial characteristics in patients with benign essential blepharospasm (BEB) compared with patients with hemifacial spasm (HFS). METHODS: Persons with BEB (n = 159) or HFS (n = 91) were identified based on International Classification of Diseases, Ninth Revision, Clinical Modifications codes with subsequent verification by record abstraction. Information regarding demographics, health characteristics, disease characteristics, and vision-targeted health-related quality of life was obtained through a telephone interview. RESULTS: For patients with BEB and HFS, the composite scores and subscale scores on the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) were low. Compared with patients with HFS, patients with BEB reported more depressive symptoms (P = .03), met the criteria for generalized anxiety disorder (P = .007), had lower NEI-VFQ-25 composite scores (P<.001), and had lower NEI-VFQ-25 subscale scores regarding general vision (P = .03), ocular pain (P<.001), distance activities (P = .001), driving (P<.001), and all of the vision-specific subscales addressing psychosocial issues. CONCLUSIONS: Compared with patients with HFS, those with BEB experience a greater reduction in vision-targeted health-related quality of life and are more prone to symptoms of depression and anxiety. This underscores the inadequacy of current treatment options for BEB in light of the fact that these patients had been undergoing standard-of-care treatments for some time.

Feasibility and efficacy of diabetic retinopathy screening among youth with diabetes in a pediatric endocrinology clinic: a cross-sectional study.

BACKGROUND: We examined the feasibility and efficacy of using a non-mydriatic camera to screen for diabetic retinopathy (DR) among youth with type 1 or type 2 diabetes seen in a pediatric endocrinology clinic serving Alabama, the state that has the highest diabetes rate in the United States. METHODS: 236 youths with type 1 or type 2 diabetes were screened for DR using a non-mydriatic camera. Visual acuity was also assessed. A questionnaire asked parents about diabetes and eye care history. RESULTS: Mean duration since diabetes diagnosis was 5.5 years. 66 % reported receiving an eye examination within the previous year. 97.5 % had images that were gradable. DR was detected in 3.8 % of participants. 9.1 % were visually impaired. CONCLUSIONS: Use of a non-mydriatic fundus camera is feasible and efficacious for DR screening in youth with diabetes. DR screening at routine endocrinology visits may be beneficial in managing youth with diabetes and preventing irreversible vision loss, particularly for those in regions where diabetes rates are high.

A population-based examination of the visual and ophthalmological characteristics of licensed drivers aged 70 and older.

BACKGROUND: Safe driving performance depends on visual skills yet little is known about the prevalence of vision impairments in older drivers and the eye conditions that cause them. This study is a population-based examination of the prevalence of vision impairment and major ophthalmological conditions among drivers aged 70 and older. METHODS: The source population was a random sample of 2,000 licensed drivers aged 70 and older residing in north central Alabama. All had driven within the past 3 months. Binocular visual acuity and contrast sensitivity were assessed. The Useful Field of View subtest 2 and Trails B assessed visual processing speed. Ophthalmological diagnoses for cataract, intraocular lens placement, glaucoma, diabetic retinopathy, age-related macular degeneration, and diabetic retinopathy were obtained through medical records from the most recent eye examination. RESULTS: Ninety-two percent of drivers had visual acuity of 20/40 or better; only two drivers (0.1%) had acuity worse than 20/100. Ninety-three percent had normal contrast sensitivity (≥1.5). About 40% had slowed visual processing speed (44%, Useful Field of View; 38%, Trails B). The most common eye condition was cataract, with more than half having cataract in one or both eyes (56%); yet by the 80s and 90s, the prevalence was low, with most drivers having undergone cataract surgery and intraocular lens placement. CONCLUSIONS: This population-based study suggests that serious impairment in central vision-visual acuity or contrast sensitivity-is rather uncommon in older drivers; however, slowed visual processing speed is common.

Medical record validation of self-reported eye diseases and eye care utilization among older adults.

PURPOSE: Vision impairment is an important public health concern. Accurate information regarding visual health and eye care utilization is essential to monitor trends and inform health policy interventions aimed at addressing at-need populations. National surveys provide annual prevalence estimates but rely on self-report. The validity of self-reported information regarding eye disease has not been adequately explored. METHODS: This cross-sectional study compared self-report of eye care utilization and eye disease with information obtained from medical records. The study population was 2001 adults aged 70 years and older who completed the Behavioral Risk Factor Surveillance System's Visual Impairment and Access to Eye Care Module. Cohen's kappa (κ) was used to assess agreement. RESULTS: Agreement between self-report and medical records was substantial for eye care utilization (κ = 0.64) and glaucoma (κ = 0.73), moderate for macular degeneration (κ = 0.40) and diabetic retinopathy (κ = 0.47) and slight for cataracts (κ = 0.18). Self-report tended to overestimate the number of subjects who visited an eye care provider in the previous year, and underestimated the prevalence in all but one (glaucoma) of the four eye diseases evaluated. CONCLUSIONS: Though agreement was substantial for self-report of eye care utilization, results of the current study suggest that national estimates based on self-report overestimate eye care utilization.

Characteristics of on-road driving performance of persons with central vision loss who use bioptic telescopes.

PURPOSE: To compare the on-road driving performance of visually impaired drivers using bioptic telescopes with age-matched controls. METHODS: Participants included 23 persons (mean age = 33 ± 12 years) with visual acuity of 20/63 to 20/200 who were legally licensed to drive through a state bioptic driving program, and 23 visually normal age-matched controls (mean age = 33 ± 12 years). On-road driving was assessed in an instrumented dual-brake vehicle along 14.6 miles of city, suburban, and controlled-access highways. Two backseat evaluators independently rated driving performance using a standardized scoring system. Vehicle control was assessed through vehicle instrumentation and video recordings used to evaluate head movements, lane-keeping, pedestrian detection, and frequency of bioptic telescope use. RESULTS: Ninety-six percent (22/23) of bioptic drivers and 100% (23/23) of controls were rated as safe to drive by the evaluators. There were no group differences for pedestrian detection, or ratings for scanning, speed, gap judgments, braking, indicator use, or obeying signs/signals. Bioptic drivers received worse ratings than controls for lane position and steering steadiness and had lower rates of correct sign and traffic signal recognition. Bioptic drivers made significantly more right head movements, drove more often over the right-hand lane marking, and exhibited more sudden braking than controls. CONCLUSIONS: Drivers with central vision loss who are licensed to drive through a bioptic driving program can display proficient on-road driving skills. This raises questions regarding the validity of denying such drivers a license without the opportunity to train with a bioptic telescope and undergo on-road evaluation.

Trial frame refraction versus autorefraction among new patients in a low-vision clinic.

PURPOSE: To determine the relationship between refractive error as measured by autorefraction and that measured by trial frame refraction among a sample of adults with vision impairment seen in a university-based low-vision clinic and to determine if autorefraction might be a suitable replacement for trial frame refraction. METHODS: A retrospective chart review of all new patients 19 years or older seen over an 18-month period was conducted and the following data collected: age, sex, primary ocular diagnosis, entering distance visual acuity, habitual correction, trial frame refraction, autorefraction, and distance visual acuity measured after trial frame refraction. Trial frame refraction and autorefraction were compared using paired t-tests, intraclass correlations, and Bland-Altman plots. RESULTS: Final analyses included 440 patients for whom both trial frame refraction and autorefraction data were available for the better eye. Participants were mostly female (59%) with a mean age of 68 years (SD = 20). Age-related macular degeneration was the most common etiology for vision impairment (44%). Values for autorefraction and trial frame refraction were statistically different, but highly correlated for the spherical equivalent power (r = 0.92), the cylinder power (r = 0.80) and overall blurring strength (0.89). Although the values of the cross-cylinders J(0) and J(45) were similar, they were poorly correlated (0.08 and 0.15, respectively). The range of differences in spherical equivalent power was large (-8.6 to 4.9). CONCLUSIONS: Autorefraction is highly correlated with trial frame refraction. Differences are sometimes substantial, making autorefraction an unsuitable substitute for trial frame refraction.

Examining the association between age-related macular degeneration and motor vehicle collision involvement: a retrospective cohort study.

BACKGROUND: Little is known about motor vehicle collision (MVC) risk in older drivers with age-related macular degeneration (AMD). The purpose of this study is to examine associations between MVC involvement and AMD presence and severity. METHODS: In a retrospective cohort study pooling the samples from four previous studies, we examined associations between MVC rate and older drivers with early, intermediate or advanced AMD as compared with those in normal eye health. MVC data were based on accident reports obtained from the state agency that compiles this information. RESULTS: MVC rate was highest among those in normal eye health and progressively declined among those with early and intermediate disease, and then increased for those with advanced AMD. However, only for drivers with intermediate AMD was the MVC rate significantly different (lower) as compared with those in normal eye health, regardless of whether the rate was defined in terms of person-years (RR 0.34, 95% CI 0.13 to 0.89) or person-miles (RR 0.35, 95% CI 0.13 to 0.91) of driving. CONCLUSIONS: These results suggest that older drivers with intermediate AMD have a reduced risk of collision involvement. Further research should investigate whether self-regulatory driving practices by these drivers (avoiding challenging driving situations) underlies this reduced risk.

Characteristics of low-vision rehabilitation services in the United States.

OBJECTIVES: To describe characteristics of services, providers, and patients in low-vision rehabilitation entities serving adults in the United States. METHODS: Entities (excluding Veterans Affairs clinics) were identified through professional associations, Web searches, and a telephone survey to retina practices. A census obtained information on entity types, provider types, rehabilitation services available, and clientele. Surveys were administered by telephone, fax, e-mail, or mail, whichever was preferred by the respondent. RESULTS: A total of 1228 low-vision rehabilitation service entities were identified, with 608 surveyed (49.5% response rate). Almost half (42.7%) were private optometry practices. State agencies had the highest number of clients per week (45.0 clients per week) whereas private optometry practices had the lowest (4.1 clients per week). Most (> or =88.0%) established rehabilitation goals, fit optical aids with basic training, and conducted eye examinations. Scanning, eccentric viewing, orientation and mobility, and advanced device training were less commonly offered (25%-50% of entities). Central vision impairment was the most common deficit (74.1% of clients), with age-related macular degeneration being the most common cause (67.1%). Among the clients, 85.9% had problems reading and 67.7% had problems driving; 44.9% had adjustment disorders. Almost 1 in 3 clients was aged 80 years or older. CONCLUSION: This census for the first time characterizes usual-care low-vision rehabilitation services in the United States for nonveteran adults.

On-road driving performance by persons with hemianopia and quadrantanopia.

PURPOSE: This study was designed to examine the on-road driving performance of drivers with hemianopia and quadrantanopia compared with age-matched controls. METHODS: Participants included persons with hemianopia or quadrantanopia and those with normal visual fields. Visual and cognitive function tests were administered, including confirmation of hemianopia and quadrantanopia through visual field testing. Driving performance was assessed using a dual-brake vehicle and monitored by a certified driving rehabilitation specialist. The route was 14.1 miles of city and interstate driving. Two "back-seat" evaluators masked to drivers' clinical characteristics independently assessed driving performance using a standard scoring system. RESULTS: Participants were 22 persons with hemianopia and 8 with quadrantanopia (mean age, 53+/-20 years) and 30 participants with normal fields (mean age, 52+/-19 years). Inter-rater agreement for back-seat evaluators was 96%. All drivers with normal fields were rated as safe to drive, while 73% (16/22) of hemianopic and 88% (7/8) of quadrantanopic drivers received safe ratings. Drivers with hemianopia or quadrantanopia who displayed on-road performance problems tended to have difficulty with lane position, steering steadiness, and gap judgment compared to controls. Clinical characteristics associated with unsafe driving were slowed visual processing speed, reduced contrast sensitivity and visual field sensitivity. CONCLUSIONS: Some drivers with hemianopia or quadrantanopia are fit to drive compared with age-matched control drivers. Results call into question the fairness of governmental policies that categorically deny licensure to persons with hemianopia or quadrantanopia without the opportunity for on-road evaluation.

Benign essential blepharospasm: risk factors with reference to hemifacial spasm.

BACKGROUND: To identify risk factors associated with benign essential blepharospasm (BEB) with reference to hemifacial spasm (HFS). Persons with BEB and HFS experience similar physical symptoms, yet the two disorders have different etiologies. METHODS: Patients with BEB (n = 159) or HFS (n = 91) were identified from two large neuro-ophthalmology clinics. Demographic, medical, behavioral, and psychological characteristics were obtained from chart review and a telephonic survey questionnaire. RESULTS: The average age of BEB and HFS was 66 years. Most patients in both groups were retired, white, and female. BEB patients were more than two times as likely to meet the diagnostic criteria for generalized anxiety disorder than HFS patients (odds ratio, 2.13; 95% confidence interval, 1.22-3.72). There was no difference between the two groups regarding demographics, smoking, a family history of dystonia, Parkinson disease, Bell palsy, Tourette disorder, obsessive compulsive symptoms, history of head trauma, alcohol use, or caffeine consumption. CONCLUSIONS: As compared to HFS, BEB was significantly more often associated with generalized anxiety disorder. Given the similarity of other clinical features of these two disorders, it is reasonable to conclude that anxiety is a cause not a consequence of BEB. Contrary to previous studies, BEB was not associated with obsessive-compulsive symptoms, head trauma, Parkinson disease, Bell palsy, Tourette disorder, or lack of smoking.