Health economic evaluation of a nurse-assisted online eye screening in home healthcare to reduce avoidable vision impairment (iScreen): study protocol for a cluster randomized controlled trial.

BACKGROUND: Among older people undiagnosed and untreated vision impairment and blindness are common. The leading causes are uncorrected refractive errors and cataracts. Vision problems are associated with a lower quality of life, several health problems, and a higher chance of falling accidents and fractures. To eliminate avoidable vision impairment and blindness, targeted eye screening programs are recommended. Older patients, receiving home healthcare, have not yet been considered as a population at risk who could benefit from eye screening. METHODS: A cluster-randomized controlled trial will be conducted to investigate the cost-effectiveness and cost-utility of online nurse-assisted eye screening in home healthcare, compared to care as usual, in reducing avoidable vision impairment. A healthcare and societal perspective will be used. The study will be performed in collaboration with several home healthcare organizations in the Netherlands. The online eye screening consists of near and distance visual acuity, followed by an Amsler grading test. Measurements in both groups will take place at baseline and after 6 and 12 months of follow-up. A total of 240 participants will be recruited. Older men and women (65 +), who receive home-based nursing and are cognitively able to participate, will be included. The primary outcome will be the change of two lines or more on the Colenbrander-1 M visual acuity chart between baseline and 12-month follow-up. DISCUSSION: An eye screening for populations at risk contributes to the detection of undiagnosed and untreated vision impairment. This may reduce the health-related consequences of vision loss and the high economic burden associated with vision impairment. TRIAL REGISTRATION: ClinicalTrials.gov NCT06058637. Registered on 27 September 2023.

Comparison of Eye Tracking and Teller Acuity Cards for Visual Acuity Assessment in Pediatric Cortical/Cerebral Visual Impairment.

PURPOSE: To compare eye tracking and Teller acuity cards (TAC) for assessment of visual acuity in children with cortical, or cerebral, visual impairment (CVI). DESIGN: Reliability and validity study. METHODS: We recruited 41 children with CVI from a single academic pediatric neuro-ophthalmology clinic. All children performed eye tracking to measure visual acuity, and 26 children completed TAC assessment by a masked examiner. Additionally, 2 pediatric neuro-ophthalmologists graded visual behavior using the 6-level Visual Behavior Scale (VBS). Eye tracking and TAC were performed at baseline and at 1 month. Test-retest reliability of eye tracking and TAC were assessed using the intraclass correlation coefficient (ICC). Eye tracking and TAC visual acuities were correlated with one another and VBS scores using the Spearman correlation coefficient. RESULTS: Test-retest reliability was excellent for eye tracking measurement of visual acuity (ICC = 0.81, P < .0001). For pediatric CVI, TAC test-retest reliability was fair (ICC = 0.42, P = .04). There was a moderate correlation between eye tracking and TAC (r = 0.43, P = .03) and between TAC and VBS score (r = 0.50, P = .009), and a strong correlation between eye tracking grating acuity and VBS score (r = 0.72, P < .0001). CONCLUSIONS: In our cohort of children with CVI, grating acuity measured by eye tracking demonstrated higher test-retest reliability and stronger correlation with pediatric neuro-ophthalmologic assessment of visual behavior than Teller acuity. Objective determination of gaze direction by an eye tracking camera may be more accurate than human assessment in this population. Future research is needed to determine the optimal methods of longitudinal assessment of visual function and functional vision in children with CVI.

Validation of the Austin Assessment: A screening tool for cerebral visual impairment related visual issues.

Cerebral visual impairment is the most common cause of vision impairment affecting children in the economically developed world with a prevalence rate of approximately 3.4%. Currently there are limited options for screening for cerebral visual impairment, resulting in many children going undiagnosed, especially those that have normal visual acuity. The aim of this research was to validate an iPad App called the Austin Assessment, which was developed as a potential screening tool for cerebral visual impairment related visual issues. The research involved three separate phases: (1) creating a database of normative ranges for children aged 5-18 across the different variables of the Austin Assessment, (2) using the Austin Assessment to screen children aged 5-13 to assess the effectiveness of the Austin Assessment as a screening tool for CVI related visual issues, and (3) conducting specific validation research assessing children using the Austin Assessment and an already validated visual search tool. Each phase used different quantitative research methodologies to help show the effectiveness of the Austin Assessment as a screening tool for cerebral visual impairment related visual issues. From phase one of the research, thresholds were established for three variables of the Austin Assessment for the age groupings of 5-8, 9-12 and 13-18. If a child meets one of these thresholds this indicates further assessment is required to determine if they do in fact have cerebral visual impairment related visual issues. Phase two identified 17 children out of 270 who had clinical findings indicating visual issues; potentially indicative of CVI; investigation into the nature of these visual issues is ongoing. Phase three found that the Austin Assessment has moderate diagnostic value for each age group, with good sensitivity and specificity, making it effective at distinguishing those children who have visual issues from those who have typical vision. Further investigation is needed to confirm this initial validation.

Commentary: Profiling Children With Cerebral Visual Impairment (CVI) Using Multiple Methods of Assessment to Aid in Differential Diagnosis.

PROFILING CHILDREN WITH CEREBRAL VISUAL IMPAIRMENT USING MULTIPLE METHODS OF ASSESSMENT TO AID IN DIFFERENTIAL DIAGNOSIS: Amanda H. Lueck , Gordon N. Dutton , Sylvie Chokron Seminars in Pediatric Neurology Volume 31, October 2019, Pages 5-14 Cerebral (cortical) visual impairment (CVI), the primary cause of visual impairment in chil dren in high-income countries, is increasing globally due to improved life-saving measures for premature and full-term infants. Yet the consequences of this condition are only begin ning to be understood and addressed. According to the topography, site, and the extent of the pathology, the deficit may variably concern central visual functions, visual field, percep tion of movement, visual analysis, visual exploration, attention, or visual memory, as well as visual guidance of movement. Each affected child has a unique clinical picture, which needs to be identified and individually profiled. This is probably the underlying reason that CVI is commonly underdiagnosed or misdiagnosed, especially in children, and, as a consequence, the full range of potential behavioral outcomes are not identified and adequately addressed. The present paper shows how the use of multiple methods of assessment can improve understanding of children with CVI.

Objective Assessment of Visual Field Defects Caused by Optic Chiasm and Its Posterior Visual Pathway Injury.

OBJECTIVES: To investigate the characteristics and objective assessment method of visual field defects caused by optic chiasm and its posterior visual pathway injury. METHODS: Typical cases of visual field defects caused by injuries to the optic chiasm, optic tracts, optic radiations, and visual cortex were selected. Visual field examinations, visual evoked potential (VEP) and multifocal visual evolved potential (mfVEP) measurements, craniocerebral CT/MRI, and retinal optical coherence tomography (OCT) were performed, respectively, and the aforementioned visual electrophysiological and neuroimaging indicators were analyzed comprehensively. RESULTS: The electrophysiological manifestations of visual field defects caused by optic chiasm injuries were bitemporal hemianopsia mfVEP abnormalities. The visual field defects caused by optic tract, optic radiation, and visual cortex injuries were all manifested homonymous hemianopsia mfVEP abnormalities contralateral to the lesion. Mild relative afferent pupil disorder (RAPD) and characteristic optic nerve atrophy were observed in hemianopsia patients with optic tract injuries, but not in patients with optic radiation or visual cortex injuries. Neuroimaging could provide morphological evidence of damages to the optic chiasm and its posterior visual pathway. CONCLUSIONS: Visual field defects caused by optic chiasm, optic tract, optic radiation, and visual cortex injuries have their respective characteristics. The combined application of mfVEP and static visual field measurements, in combination with neuroimaging, can maximize the assessment of the location and degree of visual pathway damage, providing an effective scheme for the identification of such injuries.

Assessment of Ocular Deformation in Pathologic Myopia Using 3-Dimensional Magnetic Resonance Imaging.

IMPORTANCE: Ocular deformation in pathologic myopia can affect the entire globe. However, few studies have investigated the equatorial pattern of ocular shape. In addition, the correlation between equatorial and posterior morphology needs to be further explored. OBJECTIVE: To assess global ocular deformation in pathologic myopia. DESIGN, SETTING, AND PARTICIPANTS: This hospital-based, cross-sectional study included 180 pathologic myopic eyes with atrophic maculopathy grading C2 (diffuse chorioretinal atrophy) or more from 180 participants who underwent comprehensive ophthalmic examination, including high-resolution 3-dimensional magnetic resonance imaging. In addition, 10 nonpathologic myopic eyes of 10 participants were set as the control group. Main Outcomes and Measures: According to the cross-sectional view of equator, equatorial shape was classified as round, rectangular, pyriform (noncircular and more protruded in 1 direction), vertical-elliptical, or horizontal-elliptical; according to the nasal and inferior views, the posterior shape was categorized as spheroidal, conical, bulb-shaped, ellipsoidal, multidistorted, and barrel-shaped. Equatorial circularity and ocular sphericity were used to quantitatively assess the morphological variability of the equatorial and posterior regions, respectively. The association between ocular morphology and ocular parameters and myopic maculopathy was also investigated. Results: The mean (SD) age of 180 participants with pathologic myopia was 55.14 (10.74) years, 127 were female (70.6%), and the mean (SD) axial length of studied eyes was 30.22 (2.25) mm. The predominant equatorial shape was pyriform (66 eyes [36.7%]), followed by round (45 eyes [25.0%]). The predominant posterior shape was bulb-shaped (97 eyes [52.2%]), followed by multidistorted (46 eyes [24.7%]). Equatorial circularity and equatorial shapes were correlated (r = -0.469; 95% CI, -0.584 to -0.346; P < .001) and ocular sphericity was correlated with posterior shapes (r = -0.533; 95% CI, -0.627 to -0.427; P < .001). In eyes with a vertical-elliptical equator, equatorial circularity and ocular sphericity were positively linearly correlated (R2 = 0.246; 95% CI, 0.050-0.496; P = .002) and the prevalence of inferior staphyloma was higher (27.8%; P = .04). Eyes with a horizontal-elliptical equator have the most horizontally oriented axis of corneal flat keratometry (median, 43.55 [interquartile range, 43.84] degrees; P = .01) and tended to present with multidistorted posterior shape (21.7%; P = .04). Conclusions and Relevance: These findings suggest ocular deformation is common in pathologic myopia and can affect the entire eye, including the equatorial and posterior regions. The morphological classification may enhance the understanding of the diverse patterns of ocular shape in pathologic myopia.

Frontloading SITA-Faster Can Increase Frequency and Reliability of Visual Field Testing at Minimal Time Cost.

PURPOSE: To report the outcomes of frontloaded visual field (VF) testing (2 tests per eye on the same visit) over 2 longitudinal, consecutive visits using SITA-Faster (SFR) in terms of global indices, reliability metrics, and test duration. DESIGN: Prospective longitudinal study. SUBJECTS: A total of 902 eyes of 463 subjects with normal, suspect, or manifest glaucoma. METHODS: Two intravisit SFR VF tests (T1 and T2) per eye at an initial (Ti) and follow-up (Tf) visit. MAIN OUTCOME MEASURES: Intra- and intervisit global indices, reliability metrics, and test durations. RESULTS: The mean age of the subjects was 63.6 years, and 58.3% were male. Seven hundred ninety eyes (87.4%) had a diagnosis of glaucoma or glaucoma suspicion. The mean duration between visits was 265.0 (standard deviation 98.8) days. In total, 3608 VF tests were analyzed, with the correlation of mean deviation (MD) values of the frontloaded tests at each visit high (T1/T2 MD correlation at initial visit r = 0.83, root mean squared error [RMSE] = 1.26, follow-up visit r = 0.83, RMSE = 1.25, P < 0.0001) and greater than the correlation of MD between visits (Ti1/Tf1 MD correlation r = 0.72, RMSE = 1.31). There was a significant intra-visit decrease in rates of abnormally high sensitivity in the glaucoma hemifield test (3.2% vs. 1.6%, P = 0.0023) and rates of unreliable test results (15.4% vs. 9.2%, P = 0.002) from T1 to T2 in both visits, with a corresponding significant decrease in MD (-1.28 dB vs. -1.68 dB, P < 0.0001) and VF index (P = 0.03). The mean duration of each SFR test was 132.6 (SD 27.2) seconds. CONCLUSIONS: Frontloading VFs using SFR produced sets of repeatable perimetric data with significant improvement of reliability indices from the first to second test. This may help increase testing frequency at minimal time cost to meet recommended guidelines and for evaluating patients prone to high variability. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Early post-operative neurodevelopment and visual assessment in neonates with congenital heart disease undergoing cardiac surgery.

OBJECTIVE: Assessment of neurobehavior and visual function of newborns with congenital heart disease during the post-operative period to identify infants at risk of neurodevelopmental and visual impairment. STUDY DESIGN: Prospective study that included 45 newborns who underwent cardiac surgery. Newborn Behavioral Observations test (NBO) and "ML Battery of Optotypes" were used for assessment. RESULTS: The median NBO global score was 2.4 [2.1-2.6]. Total days of oral morphine [p = 0.005] and total days of sedation [p = 0.009] were strongly related to abnormal evaluations. Time of cerebral regional oxygen saturation (CrSO2) under 40% during surgery and increased lactate were related to abnormal motor evaluation. Only 14.5% of patients presented pathological results in visual evaluation. CONCLUSIONS: We have demonstrated alterations in attention, autonomic, motor, and oral motor function. Duration of sedative medication, time of CrSO2 under 40% during surgery, and increased lactate are the most important risk factors. No significant visual impairment was detected.

Clinical assessment, investigation, diagnosis and initial management of cerebral visual impairment: a consensus practice guide.

Cerebral Visual Impairment (CVI) is a common condition in the UK. Patients with conditions associated with CVI are frequently seen in paediatric ophthalmology clinics offering eye care professionals an opportunity to identify children proactively. In most cases CVI occurs as part of a neurodevelopmental condition or as a feature of multiple and complex disabilities. However, CVI can also be seen in children with apparently typical development. In some cases, high contrast visual acuity is normal and in other cases severely impaired. As such, identification of CVI requires evaluation of aspects of visual performance beyond high contrast acuity and consideration that visual function of those with CVI may fluctuate. Few paediatric ophthalmologists have received formal training in CVI. The detection and diagnosis of CVI varies across the UK and patients report hugely different experiences. A diagnosis of CVI is made based on professional clinical judgement and it is recognised that individual perspectives and local practice in the specific methodologies of assessment will vary. A systematic review and survey of professionals is underway to attempt to reach agreement on diagnostic criteria. Nonetheless, established pathways and published protocols can offer guidance on how a paediatric ophthalmology service can approach assessment of the child with suspected CVI. The purpose of this paper is to present a summary of research and clinical practice methods for detecting and diagnosing CVI in a paediatric ophthalmology outpatient setting. It represents current understanding of the topic and acknowledges the evolving nature of both practice and the evidence-base. A rapid literature review was undertaken to identify articles relating to clinical investigation of children with CVI. A focus group of QTVI and subject matter experts from sight loss charities was undertaken to address areas which were not covered by the literature review.

Assessment of spectral properties of positive dysphotopsia or glare caused by LED sources for different types of intraocular lenses.

Light emitting diodes (LEDs) have become a major source of lighting conditions. The increased prevalence of LED light sources introduces new concerns for the spectral effects of positive dysphotopsia (PD) or glare type photic phenomena for pseudo-phakic patients with intraocular lenses (IOLs). A significant amount of work has been published in the area of spectral discomfort and sensitivity of LEDs as well as automotive lighting. The wavelength dependence or spectral properties of PD due to LEDs for IOLs has not been reported. This study, to our knowledge, is the first one to assess the glare characteristics of four commercially available IOL models with different material types and design features using an optical bench and non-sequential ray trace simulations with LEDs of different wavelengths. A novel approach of representing the reflected and transmitted IOL glare utilizing Fresnel coefficients is found to be in close agreement with the measurements.

Knowledge Assessment on Cortical Visual Impairment Among Ophthalmologists in Nepal.

INTRODUCTION: Cortical visual impairment (CVI) in children is a retro chiasmal visual tract disorder where there is with an impairment in the visual acuity and/or functionality of vision-guided task, including motor planning in the presence of normal ocular findings or minimal ocular morbidity. The study was conducted to assess the knowledge about CVI among ophthalmologists practicing in Nepal. MATERIALS AND METHODS: This was a cross sectional study. Data collection was done by administering a preformed, validated questionnaire that was sent via email to all the ophthalmologists registered under the Nepal Ophthalmic Society. The email mentioned the aim of the study along with the questionnaire. RESULTS: A total of 146 (37.82%) ophthalmologists responded to the questionnaire. Forty four percent of the participants were general ophthalmologists, 28% were pediatric ophthalmologists and 67% were ophthalmologists from other subspecialty. The median age of participants was 37.6 years. Most of the ophthalmologist had a good knowledge about the cause, common risk factors, clinical risk factors, management and prognosis of CVI. However only 29.5% of participants were aware of the investigation of choice for diagnosing CVI and 31.7% were aware of the leading causes of visual impairment in the developed countries. The study also established that the knowledge score was higher in pediatric ophthalmologists than the general ophthalmologist and ophthalmologists from other specialties. CONCLUSION: Most of the ophthalmologists had a good knowledge about the cause, common risk factors, clinical features, management and prognosis of CVI. However only a limited number of participants were aware of the investigation of choice for diagnosing CVI and the leading causes of visual impairment in the developed countries. Majority of the participants rarely examined patients with CVI which does not correlate with the high prevalence of perinatal hypoxia, the commonest cause of CVI, in our country.

[The ground visual field assessment, using two methods, compared with Goldmann perimetry]. / Évaluation du champ visuel au sol, selon deux méthodes, comparée avec le champ visuel de Goldmann. Validation de l'évaluation du champ visuel au sol.

In visual rehabilitation, ground visual field assessment (GVFA) makes it possible to assess the size of scotomas in connection with locomotion and to restore the width of the patient's visual field (VF). The information obtained by these tests has never been compared with Goldmann testing. The purpose of this study was to assess the reproducibility of VF measurement under different conditions (Goldmann perimetry, manual and automated GVFA). Ten patients (51.4±14.0 years, 4 men and 6 women) with tunnel fields inferior or equal to the central 25°, performed three different versions of a binocular VF assessment: Goldmann perimetry, manual GVFA, and automated GVFA. The two versions of the GVFA were performed at 1m then 5m from the patient on the ground, and finally 5m away from the patient at eye level, facing the patient. The main outcome was the total perceived surface for each test. The reproducibility of the measurement was average or good for the test at 1m (ICC=0.685 to 0.866). Conversely, it was very poor between the tests at 5m, except for the automated and manual GVFA at 5m on the ground (ICC=0.888). This study shows good reproducibility of the GVFA measurements at 1m with less reproducibility at 5m, which can be explained by difficulties in the execution of the GVFA. Among the tests, the automated GVFA appears to be more reliable than the manual GVFA and is preferred by patients.

Population-based assessment of barriers for uptake of eye care services among elderly people: Findings from rapid assessment of visual impairment studies from Telangana, India.

Purpose: To report the barriers for seeking eye care among the elderly population aged ≥60 years with avoidable vision impairment (VI) in the South Indian state of Telangana. Methods: A total of 3640 participants aged ≥60 years were recruited using cluster-random sampling. Demographic information, including presenting visual acuity, was measured using the standard Rapid Assessment of Visual Impairment (RAVI) protocol. "Avoidable VI" was considered if the VI was due to cataract or uncorrected refractive error (URE). A detailed interview was conducted using a validated questionnaire to report the barriers for not seeking eye care. Data were analyzed using the Stata statistical software version 14. Results: Prevalence of avoidable VI was 30.2% (95% CI: 28.02-31.06; n = 1102). Among those who noticed decreased vision (n = 1074), only 392 participants (36.4%) reported that they felt the need for seeking eye care. The major barriers for not seeking eye care were: cannot afford the consultation fee and services (42.0%) and no escort (25.7%). Overall, the personal barriers (57.9%) were the major reason for not seeking care, followed by economic barriers (42.0%). No significant difference was reported in barriers between the participants with unilateral and bilateral VI (>0.05). Conclusion: Overall, among the elderly people, personal and economic barriers were the major reason for not seeking eye care. Health care providers and policymakers should focus on newer models of eye care delivery to ensure better accessibility and uptake of care by the elderly people.

Longitudinal Changes in Hearing and Visual Impairments and Risk of Dementia in Older Adults in the United States.

Importance: Hearing and vision problems are individually associated with increased dementia risk, but the impact of having concurrent hearing and vision deficits, ie, dual sensory impairment (DSI), on risk of dementia, including its major subtypes Alzheimer disease (AD) and vascular dementia (VaD), is not well known. Objective: To evaluate whether DSI is associated with incident dementia in older adults. Design, Setting, and Participants: This prospective cohort study from the Cardiovascular Health Study (CHS) was conducted between 1992 and 1999, with as many as 8 years of follow-up. The multicenter, population-based sample was recruited from Medicare eligibility files in 4 US communities with academic medical centers. Of 5888 participants aged 65 years and older in CHS, 3602 underwent cranial magnetic resonance imaging and completed the modified Mini-Mental State Examination in 1992 to 1994 as part of the CHS Cognition Study. A total of 227 participants were excluded due to prevalent dementia, leaving a total of 3375 participants without dementia at study baseline. The study hypothesis was that DSI would be associated with increased risk of dementia compared with no sensory impairment. The association between the duration of DSI with risk of dementia was also evaluated. Data analysis was conducted from November 2019 to February 2020. Exposures: Hearing and vision impairments were collected via self-report at baseline and as many as 5 follow-up visits. Main Outcomes and Measures: All-cause dementia, AD, and VaD, classified by a multidisciplinary committee using standardized criteria. Results: A total of 2927 participants with information on hearing and vision at all available study visits were included in the analysis (mean [SD] age, 74.6 [4.8] years; 1704 [58.2%] women; 455 [15.5%] African American or Black; 2472 [85.5%] White). Compared with no sensory impairment, DSI was associated with increased risk of all-cause dementia (hazard ratio [HR], 2.60; 95% CI, 1.66-2.06; P < .001), AD (HR, 3.67; 95% CI, 2.04-6.60; P < .001) but not VaD (HR, 2.03; 95% CI, 1.00-4.09; P = .05). Conclusions and Relevance: In this cohort study, DSI was associated with increased risk of dementia, particularly AD. Evaluation of hearing and vision in older adults may help to identify those at high risk of developing dementia.

Neuro-ophthalmic imaging and visual assessment technology for spaceflight associated neuro-ocular syndrome (SANS).

Spaceflight associated neuro-ocular syndrome (SANS) refers to a unique collection of neuro-ophthalmic clinical and imaging findings observed in astronauts after long-duration spaceflight. Current in-flight and postflight imaging modalities (e.g., optical coherence tomography, orbital ultrasound, and funduscopy) have played an instrumental role in the understanding and monitoring of SANS development; however, the precise etiology for this neuro-ophthalmic phenomenon is still not completely understood. SANS may be a potential barrier to future deep space missions, and therefore it is critical to further elucidate the underlying pathophysiology for effective countermeasures. The complexity and unique limitations of spaceflight require careful consideration and integration of leading technology to advance our knowledge of this extraterrestrial syndrome. We describe the current neuro-ophthalmic imaging modalities and hypotheses that have improved our current understanding of SANS, discuss newer developments in SANS imaging (including noninvasive near-infrared spectroscopy) and summarize emerging research in the development of an aspirational future head-mounted virtual reality display with multimodal visual assessment technology for the detection of neuro-ocular findings in SANS.