Diabetes mellitus and incident glaucoma in Australia: a 10-year cohort study from the 45 and Up Study.

Background: Understanding the relationship between diabetes mellitus (DM) and the severity of glaucoma is important for the primary prevention of incident glaucoma. This paper aims to examine the association between DM and incident glaucoma. Methods: The 45 and Up Study is a prospective cohort study where Australians aged ≥45 years old were enrolled. The incident of glaucoma at follow-up is the main outcome measured. Glaucoma incidence was identified as those with recorded glaucoma-related medication from the Pharmaceutical Benefits Scheme or surgery recorded in the Medicare Benefits Schedule. Patients with glaucoma were classified into the medical glaucoma group (with glaucoma-related medication but not surgery) and the surgical glaucoma group (with glaucoma-related surgery). A Cox regression model was used to calculate the hazard ratios (HRs) to examine the association between baseline DM and the risk of developing glaucoma during the follow-up period. The reference groups are as follows: (I) non-DM participant; (II) participant with DM, duration between 0 and 5 years; (III) participant uses insulin. Results: A total of 255,547 eligible participants, with no glaucoma diagnosis at baseline, were included. During the follow-up period, 7,667 patients (3.0%) were identified as medical glaucoma only and 2,326 patients (0.9%) underwent glaucoma surgery. After controlling for confounders, baseline DM was associated with an increased risk of glaucoma in the medical glaucoma group only [hazard ratio (HR) =1.36, 95% confidence interval (CI) =1.07-1.72, P=0.002]. However, baseline DM (HR =0.97, 95% CI =0.57-1.65, P=0.979) was not associated with an increased risk of surgical glaucoma. Conclusions: DM was associated with an increased risk of medical glaucoma only, there was no association identified with surgical glaucoma in the Australian population recruited in the 45 and Up Study.

Geographic variation in cumulative incidence of private cataract surgery in Australia and its influencing factors: Findings from the 45 and Up Study.

PURPOSE: To investigate the geographic variation in the cumulative incidence of private cataract surgery (PCS) and its association with remoteness, socioeconomic, and private health insurance coverage indexes in a large Australian population. METHODS: A prospective population-based study of 266,896 Australian adults living in New South Wales (NSW) aged 45 years older and over were enrolled in the 45 and Up Study. PCS was identified using Medicare claims data. Participants were assigned to a Statistical Area Level 3 (SA3) based on residential postcode in NSW. Cumulative incidence of PCS (number of surgery per 100,000 population from 2006 to 2016) among 89 SA3s was calculated and standardized to the baseline population. Remoteness and socioeconomic deprivation was derived from Australian Bureau of Statistics (ABS). Private health insurance coverage rates were obtained from the baseline interview. RESULTS: A total of 257,237 participants with complete data were included in the current analysis. During the study period, a total of 67,707 cataract surgeries were performed among 39,744 participants. Cumulative incidence of PCS varied from 14,897 to 37,314 per 100,000 across 89 SA3s. Multivariable adjusted regression models showed that remoteness index and private health insurance coverage rates were independently associated with cumulative incidence of PCS (all P < 0.05), while no significant association between socioeconomic deprivation and cumulative incidence of PCS was observed. Collectively, these three variables explained 52.7% of the geographic variability. CONCLUSIONS: The geographical variation in the cumulative incidence of PCS calls for interventions targeted at individuals living in remote areas to reduce the burden of cataract-related vision impairment.

Association of glaucoma with 10-year mortality in a population-based longitudinal study in urban Southern China: the Liwan Eye Study.

OBJECTIVES: To investigate the association between glaucoma and 10-year mortality rate in an adult population in China. DESIGN: Population-based cohort study. SETTING: The Liwan Eye Study, China. PARTICIPANTS: 1405 baseline participants aged 50 years and older were invited to attend a 10-year follow-up examination. PRIMARY AND SECONDARY OUTCOME MEASURES: The International Society of Geographic and Epidemiologic Ophthalmology criteria was used to define glaucoma. Detailed information of mortality was confirmed using the Chinese Centre for Disease Control and Prevention. Presenting visual impairment (PVI) was defined as a presenting visual acuity of less than 20/40 in the better-seeing eye. The 10-year mortality rates were compared using the log-rank test. Cox proportional hazards regression models were used to investigate the association between glaucoma and mortality. RESULTS: A total of 1372 (97.7%) participants with available gonioscopic data were included in the analysis. Of these, 136 (9.9%), 33 (2.4%) and 21 (1.5%) participants had primary angle closure (PAC) suspect (PACS), PAC and PAC glaucoma (PACG), and 29 (2.1%) had primary open angle glaucoma (POAG). After 10 years, 306 (22.3%) participants were deceased. The 10-year mortality was significantly associated with PACG (HR, 2.15, 95% CI 1.14 to 4.04, p=0.018) but not associated with PAC (HR, 1.27, 95% CI 0.67 to 2.39, p=0.463), PACS (HR, 1.32, 95% CI 0.95 to 1.83, p=0.099) and POAG (HR, 0.74, 95% CI 0.36 to 1.49, p=0.395) when age and gender were adjusted for. This association was no longer statistically significant (HR, 1.60, 95% CI 0.70 to 3.61, p=0.263) when covariables, such as income, education, body mass index, PVI, history of diabetes and hypertension, were adjusted for. Larger vertical cup-to-disc ratio (VCDR >0.30) was only a significant risk factor in multivariable analysis (HR, 1.60, 95% CI 1.11 to 2.33, p=0.011). CONCLUSIONS: PACG was significantly associated with higher long-term mortality, but this association was likely to be confounded by other systemic risk factors. VCDR >0.3 was the only independent predictor, implying that it may be a marker of ageing and frailty.

Real-world artificial intelligence-based opportunistic screening for diabetic retinopathy in endocrinology and indigenous healthcare settings in Australia.

This study investigated the diagnostic performance, feasibility, and end-user experiences of an artificial intelligence (AI)-assisted diabetic retinopathy (DR) screening model in real-world Australian healthcare settings. The study consisted of two components: (1) DR screening of patients using an AI-assisted system and (2) in-depth interviews with health professionals involved in implementing screening. Participants with type 1 or type 2 diabetes mellitus attending two endocrinology outpatient and three Aboriginal Medical Services clinics between March 2018 and May 2019 were invited to a prospective observational study. A single 45-degree (macula centred), non-stereoscopic, colour retinal image was taken of each eye from participants and were instantly screened for referable DR using a custom offline automated AI system. A total of 236 participants, including 174 from endocrinology and 62 from Aboriginal Medical Services clinics, provided informed consent and 203 (86.0%) were included in the analysis. A total of 33 consenting participants (14%) were excluded from the primary analysis due to ungradable or missing images from small pupils (n = 21, 63.6%), cataract (n = 7, 21.2%), poor fixation (n = 2, 6.1%), technical issues (n = 2, 6.1%), and corneal scarring (n = 1, 3%). The area under the curve, sensitivity, and specificity of the AI system for referable DR were 0.92, 96.9% and 87.7%, respectively. There were 51 disagreements between the reference standard and index test diagnoses, including 29 which were manually graded as ungradable, 21 false positives, and one false negative. A total of 28 participants (11.9%) were referred for follow-up based on new ocular findings, among whom, 15 (53.6%) were able to be contacted and 9 (60%) adhered to referral. Of 207 participants who completed a satisfaction questionnaire, 93.7% specified they were either satisfied or extremely satisfied, and 93.2% specified they would be likely or extremely likely to use this service again. Clinical staff involved in screening most frequently noted that the AI system was easy to use, and the real-time diagnostic report was useful. Our study indicates that AI-assisted DR screening model is accurate and well-accepted by patients and clinicians in endocrinology and indigenous healthcare settings. Future deployments of AI-assisted screening models would require consideration of downstream referral pathways.

A survey of clinicians on the use of artificial intelligence in ophthalmology, dermatology, radiology and radiation oncology.

Artificial intelligence technology has advanced rapidly in recent years and has the potential to improve healthcare outcomes. However, technology uptake will be largely driven by clinicians, and there is a paucity of data regarding the attitude that clinicians have to this new technology. In June-August 2019 we conducted an online survey of fellows and trainees of three specialty colleges (ophthalmology, radiology/radiation oncology, dermatology) in Australia and New Zealand on artificial intelligence. There were 632 complete responses (n = 305, 230, and 97, respectively), equating to a response rate of 20.4%, 5.1%, and 13.2% for the above colleges, respectively. The majority (n = 449, 71.0%) believed artificial intelligence would improve their field of medicine, and that medical workforce needs would be impacted by the technology within the next decade (n = 542, 85.8%). Improved disease screening and streamlining of monotonous tasks were identified as key benefits of artificial intelligence. The divestment of healthcare to technology companies and medical liability implications were the greatest concerns. Education was identified as a priority to prepare clinicians for the implementation of artificial intelligence in healthcare. This survey highlights parallels between the perceptions of different clinician groups in Australia and New Zealand about artificial intelligence in medicine. Artificial intelligence was recognized as valuable technology that will have wide-ranging impacts on healthcare.

Distribution of intraocular pressure and related risk factors in a highly myopic Chinese population: an observational, cross-sectional study.

Clinical relevance: Those with high myopia are more likely to have glaucoma compared to those without myopia and intraocular pressure was a key factor for developing glaucoma. Thus, investigating the distribution of intraocular pressure and associated factors among those with high myopia is of high importance.Background: The aim of this work is to investigate the distribution of intraocular pressure and the correlated risk factors in a highly myopic Chinese population.Methods: A total of 884 Chinese participants with bilateral high myopia (≤ -6.00 D spherical power) were included from the Zhongshan Ophthalmic Center-Brien Holden Vision Institute High Myopia Cohort Study. All participants underwent a comprehensive ocular examination, including ocular biometry, cycloplegic refractometry, and intraocular pressure measurement with Goldmann applanation tonometry. Information on smoking and drinking status was also collected.Results: The mean spherical equivalence of left eyes was -10.02 ± 3.58 D with a mean axial length of 27.48 ± 1.55 mm. The overall mean intraocular pressure was 15.1 ± 2.4 mmHg (95% confidence interval, 15.0 to 15.3 mmHg). The intraocular pressure in the -6.00D to -7.99D spherical equivalence group, -8.00D to -9.99D spherical equivalence group, and ≤ -10.00 D group were 15.3 ± 2.4 mmHg, 15.1 ± 2.5 mmHg, and 15.0 ± 2.4 mmHg, respectively (p = 0.979). In multiple regression models, intraocular pressure in high myopes was not associated with spherical equivalence (p = 0.354) or axial length (p = 0.601), but significantly higher in those who were younger (non-standardised beta, -0.018; p = 0.007), smoked tobacco (non-standardised beta, 1.085; p = 0.001) and had greater central corneal thickness (non-standardised beta, 0.021; p < 0.001).Conclusion: Intraocular pressure was 15.1 ± 2.4 mmHg among subjects with a mean age of 22.8 years in this highly myopia Chinese population. These findings suggested that highly myopic Chinese persons of a younger age and greater central corneal thickness were more likely to have higher intraocular pressure.

Visual impairment and ten-year mortality: the Liwan Eye Study.

OBJECTIVES: To explore associations between visual impairment (VI) and mortality in an adult population in urban China. METHODS: The Liwan Eye Study was a population-based prevalence survey conducted in Guangzhou, Southern China. The baseline examination was carried out in 2003. All baseline participants were invited for the 10-year follow-up visit. VI was defined as the visual acuity of 20/40 or worse in the better-seeing eye with habitual correction if worn. Correctable VI was defined as the VI correctable to 20/40 or better by subjective refraction, and non-correctable VI was defined as the VI correctable to worse than 20/40. Mortality rates were compared using the log-rank test and Cox proportional hazards regression models. RESULTS: Of the 1399 participants (mean age: 65.3 ± 9.93 years; 56.4% female) with available baseline visual acuity measurement, 320 participants (22.9%) had VI. After 10 years, 314 (22.4%) participants died. Visually impaired participants had a significantly increased 10-year mortality compared with those without VI (40.0% vs. 17.2%, P < 0.05). After adjusting for age, gender, income, educational attainment, BMI, history of diabetes and hypertension, both VI (HR, 1.55; 95% CI, 1.14-2.11) and non-correctable VI (HR, 2.72; 95% CI, 1.86-3.98) were significantly associated with poorer survival, while correctable VI (HR, 0.99; 95% CI, 0.66-1.49) was not an independent risk factor for 10-year mortality. CONCLUSIONS: Our findings that VI, particularly non-correctable VI, predicting poorer survival may imply the underlying mechanism behind VI-mortality association and reinforce the importance of preventing and treating disabling ocular diseases to prevent premature mortality in the elderly.

How Does Cataract Surgery Rate Affect Angle-closure Prevalence.

PRCIS: A data simulation study suggests that prevalence of occludable angle will decrease when the cataract surgical rate increases in particularly when the surgery focuses on 70+ years old. PURPOSE: The purpose of this study was to estimate the effects of cataract surgical rates (CSR) on the prevalence of primary angle-closure glaucoma in the Chinese population. METHODS: Participants aged 50 years and older from the Liwan Eye Study were included as the study sample. Occludable angle (OA) as a surrogate of primary angle-closure glaucoma was evaluated using static gonioscopy and anterior chamber depth was measured before dilation using A-mode ultrasound. Random sampling was used to generate 50 cohorts with a sample size of 200 for each predefined CSR at 2000, 4000, 6000, 8000, 10,000, 12,000, according to the multinomial distribution. The mean anterior chamber depth and OA rates of each cohort were calculated. Logistic function models of nonlinear least-squares estimation were used to predict the prevalence of OA. RESULTS: Data of the right eye from 1280 participants were included. The prevalence of cataract surgery and OA was 2.27% and 11.3%, respectively. The projected prevalence of OA in the cohorts with CSR of 2000, 4000, 6000, 8000, 10,000 and 12,000 was 11.4% [95% confidence interval (CI), 10.8%-12.0%], 11.2% (95% CI, 10.6%-11.9%), 10.9% (95% CI, 10.3%-11.6%), 11.4% (95% CI, 10.8%-12.1%), 10.8% (95% CI, 10.2-11.4%), and 10.1% (95% CI, 9.46-10.7%), respectively. The OA rates decreased remarkably as CSR increased for those aged 70 years and older. CONCLUSIONS: Our study indicated that with CSR increased, the OA prevalence could decrease remarkably especially in the older population. It is advisable to perform cataract surgery at an appropriate time for patients in their late 60s to 70s with significant cataracts.

Visual impairment in highly myopic eyes: The ZOC-BHVI High Myopia Cohort Study.

IMPORTANCE: Understanding visual impairment (VI) under different definitions and potential risk factors in high myopic is important for future myopia control. BACKGROUND: Limited studies exists investigating the VI among high myopic and with varying VI definitions. DESIGN: Registry cohort study. PARTICIPANTS: Eight hundred and eighty-four participants were from ZOC-BHVI study. METHODS: Subjects aged 7 to 70 years with high myopia were enrolled. Uncorrected visual acuity and best-corrected visual acuity (UCVA and BCVA), cycloplegic refraction, axial length (AL), corneal curvatures, anterior chamber depth and lens thickness were measured. Axial length/corneal radius of curvature ratio (AL/CR ratio) was calculated. Fundus lesions were graded into five categories. VI and blindness were defined based on the better-seeing eye according to the World Health Organization (WHO) criteria and US criteria. Multiple logistic regression analysis was used to assess risk factors for VI. MAIN OUTCOME MEASURES: Rates of VI and blindness. RESULTS: A total of 884 participants were included, with mean (SD) age 18.5 (12.4) years and 46.4% male. Rate of UCVI/blindness were 72.6%/27.3% and 17.9%/82.1% based on WHO and US criteria. With respect to BCVA, 4.1%/5.9% of participants had BCVI using two definitions, whereas the rate for blindness was 0.2% and 0.6%. After adjusting confounders, multiple logistic regression showed that more severe fundus lesions, greater AL/CR ratio were at a higher risk of being VI, both in two definitions (P < .005). CONCLUSIONS AND RELEVANCE: The rate of VI and blindness in highly myopic patients varies significantly using different definition. Severe fundus lesions and greater AL/CR ratios were associated with a higher risk of VI.

The Association between Retinopathy and Arthritis: Findings from a US National Survey 2005-2008.

Objective To explore the association between retinopathy and arthritis in a representative sample in the United States. Methods National Health and Nutrition Examination Survey (NHANES) is a series of biannual surveys in a nationally representative non-institutionalized population of the United States. Two waves of NHANES (2005-2008) were merged in the current analysis. Arthritis status and types of arthritis were obtained from questionnaires. Non-mydriatic fundus photographs were collected among participants aged 40 years and older and retinopathy status was assessed using the Airlie House classification scheme. The association between arthritis and retinopathy was evaluated using logistic regression models. Results From 6,797 eligible participants, 4,901 had information in terms of arthritis status and gradable fundus photographs of at least 1 eye. Retinopathy was less prevalent in patients with osteoarthritis compared with those without osteoarthritis (11.9% vs 17.5%, P < .05). Participants who had osteoarthritis had 43% reduced relative risk of retinopathy compared to those without, after adjusting for covariates (Odds Ratio [OR] = 0.57, 95% Confidence Interval [CI]: 0.33-0.98). This significant association persisted among diabetic participants (OR = 0.43, 95% CI: 0.19-1.00). However, no significant associations between any arthritis, rheumatoid arthritis, other types of arthritis and retinopathy were noted. Conclusions Patients with osteoarthritis were less likely to have retinopathy when compared with those without. Further studies investigating the possible protective effects of arthritis physiology and/or arthritis treatment in retinopathy are needed.

Visual Impairment and Major Eye Diseases in Chronic Kidney Disease: The National Health and Nutrition Examination Survey, 2005-2008.

PURPOSE: To investigate the prevalence and associations of visual impairment (VI) and major eye diseases with chronic kidney disease (CKD) in the United States. DESIGN: Cross-sectional study. METHODS: We investigated the prevalence and associations of VI and major eye diseases with CKD among 5,518 participants aged 40 years or older in the 2005-2008 National Health and Nutrition Examination Survey. An estimated glomerular filtration rate of lower than 60 mL/min/1.73 m2 was defined as CKD. Corrected visual acuity of worse than 20/40 in the better-seeing eye was defined as VI. Major eye diseases, including any ocular disease, any objectively determined ocular disease, cataract surgery, any retinopathy, diabetic retinopathy (DR), age-related macular degeneration (AMD), and glaucoma were evaluated from questionnaire or retinal photographs using standardized grading protocols. RESULTS: The prevalence of VI and major eye diseases were approximately 2- to 7-fold higher in participants with CKD than in those without (all P < .05). After controlling for multiple confounders, the presence of CKD was associated with VI (odds ratio [OR]: 2.01, 95% confidence interval [CI]: 1.14-3.54), any ocular disease (OR: 1.65, 95% CI: 1.22-2.22), any objectively determined ocular disease (OR: 1.52, 95% CI: 1.06-2.19), any retinopathy (OR: 1.70, 95% CI: 1.18-2.45), and DR (OR: 2.34, 95% CI: 1.23-4.42). There was no association of CKD with cataract surgery, AMD, or glaucoma. A significant association between CKD and any ocular disease was observed among nondiabetic participants. The presence of CKD was closely related to VI and any retinopathy among diabetic participants. CONCLUSIONS: This nationally representative sample of the US population demonstrated high prevalence and strong associations of VI and major eye diseases with CKD, highlighting the importance of ocular screening among CKD patients and potential common pathogenesis underlying these conditions.

Age-related cataract and 10-year mortality: the Liwan Eye Study.

PURPOSE: To explore the association between age-related cataract and 10-year mortality in an adult population in urban China. METHODS: A total of 1405 participants aged 50 years or older were examined at baseline in the Guangzhou Liwan Eye Study. All participants were invited to attend a 10-year follow-up visit. Cataract cases were defined as either having visible lens opacity confirmed with direct ophthalmoscope under pupil dilation or previous history of cataract surgery. Visual impairment (VI) was defined as a visual acuity of 20/40 or worse in the better-seeing eye with habitual correction if worn. Body mass index (BMI) was based on anthropometric data. A brief questionnaire regarding family income, educational attainment and medical history of systemic disease was administered. Mortality rates were compared using the log-rank test and Cox proportional hazards regression models. RESULTS: Among 1405 participants examined at baseline, 957 participants (68.1%) had visible lens opacity or history of cataract surgery. After 10 years, 320 (22.8%) participants died. The 10-year mortality rate was significantly higher in participants with cataract than in those without (30.1% versus 7.14%, log-rank p < 0.05). After adjusting for age, gender, family income, educational attainment, BMI, history of diabetes and hypertension and presence of VI, presence of cataract predicted a nearly threefold increase in the risk of mortality (HR, 2.99; 95% CI, 1.89-4.71). CONCLUSIONS: Our findings that age-related cataract is a predictor for poorer survival compared to those without may imply that cataract is a biomarker of ageing and frailty.

Five-year changes in anterior segment parameters in an older population in urban southern China: the Liwan Eye Study.

PURPOSE: To investigate the 5-year changes in static and dynamic anterior segment optical coherence tomography (AS-OCT) parameters and their predictors. METHODS: This was a prospective, population-based cohort study of people aged 50 years and older residing in the Liwan District, Guangzhou, China. Standardised AS-OCT scans were performed in November 2008 and November 2013 under dark and light conditions. Customised software was used to analyse horizontal AS-OCT images. Parameters in dark and measurements of light-to-dark changes were used for analyses. RESULTS: A total of 186 (71.8%) subjects underwent AS-OCT twice, 5 years apart and were included for analyses. The mean age in 2008 was 64.7±7.0 years, and 60.2% were women. The anterior chamber width (ACW) decreased from 11.74±0.44 mm in 2008 to 11.60±0.37 mm in 2013 (p=0.001). There was a trend towards a decrease in dynamic capacity (light-to-dark changes) in the anterior segment, with decreased iris thickness at 750 µm (ΔIT750), ΔACW, Δ anterior chamber area (ACA) and Δ pupil diameter at 5 years (all p<0.05). After adjusting for age and sex, the following baseline parameters were associated with a greater decrease rate in trabecular iris space area at 500 µm (TISA500) at 5 years: TISA500, IT750 and ACA in dark (p<0.001 for all). CONCLUSIONS: Anterior chamber angle width decreased and the amount of light-to-dark changes declined during 5-year follow-up. Subjects with greater height, wider angle width and thicker iris at baseline have greater angle narrowing at follow-up.

Prevalence, associations and characteristics of severe uncorrected refractive error in the Australian National Eye Health Survey.

IMPORTANCE: In Australia, nationally representative data of the burden and associations of severe uncorrected refractive error are scarce. BACKGROUND: To report the prevalence and characteristics of severe uncorrected refractive error in Indigenous and non-Indigenous Australians. DESIGN: Population-based cross-sectional study. PARTICIPANTS: A total of 3098 non-Indigenous Australians aged 50 to 98 and 1738 Indigenous Australians aged 40 to 92 living in 30 randomly selected Australian sites were examined. METHODS: Severe uncorrected refractive error was defined as an improvement of ≥2 lines on the logMAR chart in one or both eyes in participants with a presenting visual acuity <6/12. MAIN OUTCOME MEASURE: Severe uncorrected refractive error RESULTS: Prevalence of severe uncorrected refractive error was 11.0% (95% confidence interval 9.3-13.0) in non-Indigenous and 14.5% (12.5-16.7) in Indigenous Australians. Eighty-two percent of non-Indigenous and 77% of Indigenous participants had a spherical equivalent refraction between -2.00D and +2.00D. Indigenous Australians who were older (odds ratio [OR] for 70-79 years vs 40-49 years = 3.59), resided in outer regional areas (OR = 1.78) and did not have an eye examination in the previous 2-years (OR = 1.50) were associated with higher odds of severe uncorrected refractive error. Geographical remoteness (OR = .68 for inner regional), male gender (OR = 1.30), older age (OR for 70-79 years vs 50-59 years = 1.51) and failure to have an eye examination in the previous 2-years (OR = 2.06) were associated with severe uncorrected refractive error among non-Indigenous participants. CONCLUSIONS AND RELEVANCE: Increased public awareness of the importance of regular optometric examinations may be required in groups at high risk of severe uncorrected refractive error.

Association between age-related macular degeneration and subjective cognitive complaints.

PURPOSE: To investigate the association between age-related macular degeneration (AMD) and subjective cognitive complaints (SCCs) in the USA. METHODS: A total of 5604 participants aged 40 years and older from the 2005-2008 National Health and Nutrition Examination Survey were included. Retinal photography was graded into no AMD, early and late AMD based on the modification of the Wisconsin Age-Related Maculopathy Grading System. SCCs were based on the self-reported difficulty in remembering or confusion. Sample weights were used to generate nationally representative data. Multivariate regression analyses were used to assess the association between AMD severity and SCCs, controlling for potential confounders. RESULTS: Participants with any AMD had higher prevalence of SCCs relative to participants without AMD (6.8% vs 13.6%, p<0.001). After adjusting for potential confounding factors, presence of any AMD was significantly associated with 1.62-fold higher odds of having SCCs (95% CI 1.16 to 2.27, p=0.007). Similarly, participants with early (OR 1.58; 95% CI 1.14 to 2.17, p=0.007) and late AMD (OR 2.02; 95% CI 1.08 to 3.79, p=0.030) were also associated with elevated odds of reporting SCCs after controlling for confounders. CONCLUSIONS: We found significant associations between AMD severity and SCCs in this US population. More attention should be paid on the subjective memory function and potential risk of cognitive decline among patients with AMD.

Development and Validation of a Smartphone-Based Visual Acuity Test (Vision at Home).

PURPOSE: To describe the development and validation of a smartphone-based visual acuity (VA) test called Vision at home (V@home). METHODS: Three study populations (elderly Chinese, adolescent Chinese, and Australian groups) underwent distance and near VA testing using standard Early Treatment Diabetic Retinopathy Study (ETDRS) charts and the V@home device; all VA tests used tumbling E optotypes. VA tests were repeated with one eye, selected randomly. Distance VA was measured monocularly at 2 m, and near VA was measured binocularly at 40 cm. Participants also completed a questionnaire about their satisfaction with the device. V@home VA (logMAR) was compared to VA for ETDRS charts at distance and near and test-retest reliability. RESULTS: The mean difference between V@home and ETDRS distance VA across all groups ranged from -0.010 to -0.100 logMAR. Tolerant weighted kappa (TWK) agreement ranged from substantial (0.742) in the Australian group to almost perfect (0.950) in the adolescent Chinese group. There was high agreement of V@home with near ETDRS VA across all groups, with a mean difference of -0.092 to -0.042 logMAR and a TWK of 0.736 to 0.837. Test-retest reliability was also high (difference: -0.018 to 0.026) for both distance and near VA tests (95% limits of agreement: -0.289 to 0.258 for distance and -0.235 to 0.199 for near). The majority of participants were satisfied with V@home. CONCLUSIONS: V@home could accurately and reliably measure both distance and near VA and is well accepted by participants. TRANSLATIONAL RELEVANCE: The V@home system could potentially serve as a useful tool to improve eye care accessibility, especially in underdeveloped areas with limited eye care personnel and resources.

Role of Parental Refractive Status in Myopia Progression: 12-Year Annual Observation From the Guangzhou Twin Eye Study.

Purpose: We investigate the impact of parental myopia on spherical equivalent (SE) progression and axial length (AL) elongation. Methods: Children and their parents were invited for annual examinations from 2006 (baseline). Cycloplegic autorefraction and AL were measured at each visit. Parental refractive status was determined using refraction data from their baseline visit. Children were classified into five groups: no myopic parents (non-non), only one moderately myopic parent (non-moderate), only one highly myopic parent (non-high), two moderately myopic parents (moderate-moderate), and one moderately myopic or more severe and one highly myopic parent (moderate-high/high-high). The relationship between progression of SE and AL with parental refractive status was estimated by linear mixed-effects models. Data from 2006 to 2017 were analyzed in the current study. Results: A total of 1831 children were enrolled (mean age, 11 ± 2.7 years; mean standard error, -0.49 ± 2.16 diopters [D] at baseline. Myopia progressed faster for children with parental myopia (non-non group as reference, all P < 0.05), while AL elongation mirrored the change in SE (all P < 0.001 except for non-mod group P = 0.12). As for the age-specific change in SE and AL, children in the mod-high/high-high group presented with the fastest progression. Children with highly myopic parents were at higher risks of being highly myopic during adulthood (odds ratio = 13.98 and 25.71 for non-high and mod-high/high-high groups; both P < 0.001). Conclusions: SE progresses and AL elongates at a faster rate at an earlier age in children with parental myopia. Children with highly-myopic parents have higher risks of being highly myopic during adulthood.

Prevalence and risk profile of retinopathy in non-diabetic subjects: National Health and Nutrition Examination Survey 2005 to 2008.

IMPORTANCE: Recent US national population-based data on the prevalence of retinopathy in non-diabetic participants is limited. BACKGROUND: To assess the prevalence and risk factors of retinopathy in a representative US population without diabetes. DESIGN: Population-based, cross-sectional study. PARTICIPANTS: A total of 4354 non-diabetic participants 40 years and older with valid fundus photographs in the 2005 to 2008 National Health and Nutrition Examination Survey. METHODS: Diabetes mellitus was defined as glycosylated haemoglobin (HbA1c) ≥6.5%, physician diagnosis of diabetes mellitus or use of diabetic medication. Retinopathy level was based on the Modified Airlie House adaptation from the Early Treatment Diabetic Retinopathy Study (ETDRS) protocol. Risk profile was assessed from standardized interviews, clinical examinations and laboratory measurements. MAIN OUTCOME MEASURES: Prevalence and risk profile of retinopathy in non-diabetic participants. RESULTS: The overall weighted prevalence of retinopathy was 6.7% (n = 341). Among them, 98.2% (n = 331) had signs of minimal-to-mild non-proliferative retinopathy (ETDRS level 14-31) while only 1.8% (n = 10) had moderate-to-severe non-proliferative retinopathy (ETDRS level 41-51). After adjusting for multiple covariates, retinopathy signs in non-diabetic participants were associated with male gender (odds ratio [OR] 1.54; 95% confidence interval [CI] 1.22-1.93), systolic blood pressure (OR per 10 mmHg increase 1.11; 95% CI 1.03-1.19), HbA1c (OR per % increase 1.43; 95% CI 1.01-2.05) and history of stroke (OR 2.39; 95% CI 1.14-5.04). CONCLUSIONS AND RELEVANCE: Consistent with previous studies, signs of retinopathy are common in US persons without diabetes. Risk factors for retinopathy signs include gender, blood pressure, HbA1c and history of stroke.

A Randomized Trial to Increase the Assessment Accuracy of Glaucoma and Optic Disc Characteristics by Orthoptists.

INTRODUCTION: The aim of this study was to determine the accuracy of orthoptists when examining the optic disc for signs of glaucoma, and to explore the impact of targeted clinical education on accuracy. METHODS: In this randomized controlled trial, 42 monoscopic color optic disc images were presented to 46 orthoptists who assessed the likelihood of glaucoma as well as optic disc size, shape, tilting, vertical cup-to-disc ratio, cup shape, depth, presence of hemorrhage, peripapillary atrophy, and retinal nerve fiber layer. The level of agreement with specialist ophthalmologists was assessed. Participants were then randomly assigned to an experimental group (targeted postgraduate education on optic disc assessment) or to no intervention. The educational program was designed to increase knowledge of the characteristic features associated with glaucomatous optic neuropathy. All participants re-examined the included optic disc images after a period of 6 to 8 weeks. The primary outcome measure was a change in agreement between attempts. RESULTS: The education group showed significant improvements between attempts for identifying hemorrhages (P = .013), retinal nerve fiber layer defects (0.035), disc size (P = .001), peripapillary atrophy (P = .030), and glaucoma likelihood (P = .023). The control group did not show any statistically significant improvement. The intervention group showed significantly more improvement when identifying hemorrhages (P = .013), disc size (P = .001), disc shape (P = .033), and cup shape (P = .020) compared with the control group. DISCUSSION: Orthoptists who received additional postgraduate online education based on principles of adult learning were more accurate at assessing the optic disc for glaucoma. These results highlight the value of continuing education to optimize clinical practice in allied health professionals.