Personality traits and symptoms of anxiety and depression in patients with primary vitreous floaters.

PURPOSE: We investigated personality traits and symptoms of anxiety and depression in patients with primary vitreous floaters. METHODS: A U.K. sample of adult patients (> 18 years old) with vitreous floaters of a minimum of three months severe enough to seek a consultation was assessed for personality traits (The Big Five Inventory (BFI)), symptoms of depression (Patient Health Questionnaire-9), and symptoms of anxiety (Generalized Anxiety Disorder Questionnaire-7). RESULTS: 149 patients participated in the study. Compared to the general population, our sample had a significantly increased score in the domain of BFI-neuroticism (3.27 vs 2.97, ρ < 0.0001, d = 0.38) and reduced score in the domain of extraversion (2.97 vs 3.24, ρ < 0.0001, d = 0.33). Female patients scored significantly higher than male patients on BFI-neuroticism (ρ = 0.01), and on BFI-agreeableness (ρ = 0.01). Age was positively correlated with BFI-Conscientiousness (r = 0.19, ρ = 0.02) and with BFI-Agreeableness (r = 0.20, ρ = 0.01). 36% of our sample had moderate to severe symptoms of depression, and 43% had moderate to severe symptoms of anxiety. CONCLUSIONS: Our study highlights the underlying psychological traits of patients with severe vitreous floaters and particular mental health needs that deserve further consideration by ophthalmological and vision science clinicians.

Diabetic Macular Edema and Diode Subthreshold Micropulse Laser: A Randomized Double-Masked Noninferiority Clinical Trial.

PURPOSE: To determine clinical effectiveness, safety, and cost-effectiveness of subthreshold micropulse laser (SML), compared with standard laser (SL), for diabetic macular edema (DME) with central retinal thickness (CRT) < 400 µm. DESIGN: Pragmatic, multicenter, allocation-concealed, double-masked, randomized, noninferiority trial. PARTICIPANTS: Adults with center-involved DME < 400 µm and best-corrected visual acuity (BCVA) of > 24 Early Treatment Diabetic Retinopathy Study (ETDRS) letters in one/both eyes. METHODS: Randomization 1:1 to 577 nm SML or SL treatment. Retreatments were allowed. Rescue with intravitreal anti-vascular endothelial growth factor therapies or steroids was permitted if 10 or more ETDRS letter loss occurred, CRT increased > 400 µm, or both. MAIN OUTCOME MEASURES: Primary outcome was mean change in BCVA in the study eye at 24 months (noninferiority margin 5 ETDRS letters). Secondary outcomes were mean change from baseline to month 24 in binocular BCVA; CRT and mean deviation of Humphrey 10-2 visual field in the study eye; percentage meeting driving standards; EuroQoL EQ-5D-5L, 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25), and Vision and Quality of Life Index (VisQoL) scores; cost per quality-adjusted life-years (QALYs) gained; adverse effects; and number of laser and rescue treatments. RESULTS: The study recruited fully (n = 266); 87% of SML-treated and 86% of SL-treated patients had primary outcome data. Mean ± standard deviation BCVA change from baseline to month 24 was -2.43 ± 8.20 letters and -0.45 ± 6.72 letters in the SML and SL groups, respectively. Subthreshold micropulse laser therapy was deemed not only noninferior but also equivalent to SL therapy because the 95% confidence interval (CI; -3.9 to -0.04 letters) lay wholly within both upper and lower margins of the permitted maximum difference (5 ETDRS letters). No statistically significant difference was found in binocular BCVA (0.32 ETDRS letters; 95% CI, -0.99 to 1.64 ETDRS letters; P = 0.63); CRT (-0.64 µm; 95% CI, -14.25 to 12.98 µm; P = 0.93); mean deviation of the visual field (0.39 decibels (dB); 95% CI, -0.23 to 1.02 dB; P = 0.21); meeting driving standards (percentage point difference, 1.6%; 95% CI, -25.3% to 28.5%; P = 0.91); adverse effects (risk ratio, 0.28; 95% CI, 0.06-1.34; P = 0.11); rescue treatments (percentage point difference, -2.8%; 95% CI, -13.1% to 7.5%; P = 0.59); or EQ-5D, NEI-VFQ-25, or VisQoL scores. Number of laser treatments was higher in the SML group (0.48; 95% CI, 0.18-0.79; P = 0.002). Base-case analysis indicated no differences in costs or QALYs. CONCLUSIONS: Subthreshold micropulse laser therapy was equivalent to SL therapy, requiring slightly higher laser treatments.

Switchable Explosives: Performance Tuning of Fluid-Activated High Explosive Architectures.

We present our discovery of switchable high explosives (HEs) as a new class of energetic material that cannot detonate unless filled with a fluid. The performance of fluid-filled additive-manufactured HE lattices is herein evaluated by analysis of detonation velocity and Gurney energy. The Gurney energy of the unfilled lattice was 98% lower than that of the equivalent water-filled lattice and changing the fluid mechanical properties allowed tuning of the Gurney energy and detonation velocity by 8.5% and 13.4%, respectively. These results provide, for the first time since the development of HEs, a method to completely remove the hazard of unplanned detonations during storage and transport.

The impact of artificial intelligence on retinal disease management: Vision Academy retinal expert consensus.

PURPOSE OF REVIEW: The aim of this review is to define the "state-of-the-art" in artificial intelligence (AI)-enabled devices that support the management of retinal conditions and to provide Vision Academy recommendations on the topic. RECENT FINDINGS: Most of the AI models described in the literature have not been approved for disease management purposes by regulatory authorities. These new technologies are promising as they may be able to provide personalized treatments as well as a personalized risk score for various retinal diseases. However, several issues still need to be addressed, such as the lack of a common regulatory pathway and a lack of clarity regarding the applicability of AI-enabled medical devices in different populations. SUMMARY: It is likely that current clinical practice will need to change following the application of AI-enabled medical devices. These devices are likely to have an impact on the management of retinal disease. However, a consensus needs to be reached to ensure they are safe and effective for the overall population.

Current status and practical considerations of artificial intelligence use in screening and diagnosing retinal diseases: Vision Academy retinal expert consensus.

PURPOSE OF REVIEW: The application of artificial intelligence (AI) technologies in screening and diagnosing retinal diseases may play an important role in telemedicine and has potential to shape modern healthcare ecosystems, including within ophthalmology. RECENT FINDINGS: In this article, we examine the latest publications relevant to AI in retinal disease and discuss the currently available algorithms. We summarize four key requirements underlining the successful application of AI algorithms in real-world practice: processing massive data; practicability of an AI model in ophthalmology; policy compliance and the regulatory environment; and balancing profit and cost when developing and maintaining AI models. SUMMARY: The Vision Academy recognizes the advantages and disadvantages of AI-based technologies and gives insightful recommendations for future directions.

Biomarkers of macular neovascularisation activity using optical coherence tomography angiography in treated stable neovascular age related macular degeneration.

BACKGROUND: The aim of this study was to describe features of disease activity in patients with treated stable macular neovascularisation (MNV) in neovascular age related macular degeneration (nAMD) using optical coherence tomography angiography (OCTA). METHODS: Thirty-two eyes of 32 patients with nAMD were included in this prospective, observational study. These patients were undergoing treatment with aflibercept on a treat-and-extend regimen attending an extension to a 12-week treatment interval. RESULTS: All subjects had no macular haemorrhage and no structural OCT markers of active MNV activity at the index 12-week treatment extension visit. 31/32 OCTA images were gradeable without significant imaging artefact. The mean MNV size was 3.6mm2 ± 4.6mm2 and 27 (87.1%) had detectable MNV blood flow. 29/31 (93.5%) subjects had MNV with mature phenotypes including 10 non-specific, 10 tangle and 3 deadtree phenotypes. MNV halo and MNV central feeder vessel were noted in 18 (58.1%) and 19 (61.3%) of subjects respectively; only 1 (3.2%) subject was noted to have a MNV capillary fringe. CONCLUSIONS: MNV blood flow is still detectable using OCTA in the majority of subjects in this study with treated stable MNV. OCTA features associated included MNV mature phenotype, MNV feeder vessel, MNV halo and absence of capillary fringe.

IMAGE ANALYSIS OF OPTICAL COHERENCE TOMOGRAPHY SCANS TO EXPLORE ESTABLISHED AND NOVEL CHOROIDAL FEATURES IN PATIENTS WITH CENTRAL SEROUS CHORIORETINOPATHY.

PURPOSE: To explore the characteristics of choroidal tissue in patients with and without central serous chorioretinopathy (CSC) using an automated system of image analysis to determine known and novel metrics. METHODS: This was a retrospective case-control analysis of optical coherence tomography scans of patients seen at Manchester Royal Eye Hospital, UK, comparing patients with active CSC to an age-matched and gender-matched group with no CSC using a purpose-built automated system of image analysis. The expert system segments and measures established and novel features of choroid using a combination of thresholding, noise removal, and morphological techniques. RESULTS: A total of 72 patients were included in this study, with 40 included in the group with CSC and 32 patient controls with no CSC. There were significant increases from normal to CSC of median choroidal vascularity index, 54.7(median absolute deviation = 9.8) to 61.2(4.3), and all choroidal thickness indices including maximum depth, from 249.0(90.1) µm to 372.3(80.3) µm. For novel measures, there was a significant increase in tissue entropy from 6.68(0.28) to 6.95(0.17) and area of the largest five vessels from 6.28(3.04) mm2 to 9.10(3.49) mm2. The ratio of vessel lumen to stromal tissue intensity was conversely significantly reduced from 0.674(0.11) in normal patients to 0.59(0.06) in CSC. CONCLUSION: The automated system of choroidal analysis expands on the utility of known measures and introduces novel metrics. These findings contribute pathophysiological insights and metrics for further assessment and research on conditions affecting choroidal tissue.

Depression secondary to vision loss in old age and an effective rapid screening tool for undiagnosed cases.

BACKGROUND: Zenebe et al. recently stated that despite depression being a common mental health problem in the elderly population, it is underdiagnosed in over half of the cases (Zenebe et al. in Ann Gen Psychiatry, 2021). They described an extensive list of risk factors associated with geriatric depression. However, we noted that they did not include ophthalmic conditions in this list which have previously been identified as an important risk factor for depression in the elderly. MAIN BODY: To determine the extent of undiagnosed anxiety and depression in our elderly population with vision loss, we screened a cohort of our patients, over 60 years with vision loss secondary to macular disease for both conditions. Our cohort included 104 patients with mean best corrected visual acuity 0.58 LogMAR (Snellen equivalent 6/24). In this group, we identified 29.8% (31/104) and 28.8% (30/104) of patients with at least one depression or anxiety-related symptom, respectively, in the past 2 weeks. We identified 7.7% (8/104) and 3.8% (4/104) who had significant symptoms of depression and anxiety, respectively, that warranted further follow-up. Only two of these patients had previously been diagnosed with anxiety or depression with the majority having no previous history of either condition. Patients from our cohort who screened for depression or anxiety often cited frustration completing tasks and loss of independence secondary to declining vision. They also complained that the vision loss resulted in a lack of confidence which in turn resulted in social isolation and loneliness. Most of the patients welcomed referral to their GP for follow-up for input regarding their mental health and they also stated an interest in attending hospital optometry low vision services and counselling support. CONCLUSIONS: With increasing time pressures on healthcare services and the rising use of virtual clinics especially during the COVID-19 pandemic, it is still essential to screen efficiently for depression in those elderly patients who are at significant risk. There is a considerable burden of major depressive disease in the geriatric population, and we would recommend that physicians (Geriatricians, GPs, Ophthalmologists etc.) screen elderly patients with vision loss for depression using the rapid screening tool which we suggest.

A clinical and radiographic comparison of patients with psoriatic arthritis from different ethnic backgrounds.

OBJECTIVES: There are few papers concerning ethnic differences in disease expression in PsA, which may be influenced by a number of genetic, lifestyle and cultural factors. This article aims to compare clinical and radiographic phenotypes in people of South Asian (SA) and North European (NE) origin with a diagnosis of PsA. METHODS: This was a cross-sectional observational study recruiting patients of SA and NE origin from two hospitals in a well-defined area in the North of England. RESULTS: A total of 58 SA and 48 NE patients were recruited. SA patients had a more severe clinical phenotype with more tender (median 5 vs 2) and swollen (median 1 vs 0) joints, more severe enthesitis (median 3 vs 1.5), more patients with dactylitis (24% vs 8%), more severe skin disease (median PASI 2.2 vs 1) and worse disease activity as measured by the composite Psoriatic Arthritis Disease Activity Score (mean 4.5 vs 3.6). With regards to patient-completed measures, SA patients had worse impact with poorer quality of life and function (mean HAQ 0.9 vs 0.6; mean PsAQoL 10.8 vs 6.2; mean 36-item short form physical component score 33.5 vs 38.9). No significant differences in current MTX and biologics use were found. CONCLUSIONS: SA patients had a worse clinical phenotype and worse impact of disease than NE patients. Further studies are needed to confirm and explore the reasons behind these differences.

Evaluation of a New Model of Care for People with Complications of Diabetic Retinopathy: The EMERALD Study.

PURPOSE: The increasing diabetes prevalence and advent of new treatments for its major visual-threatening complications (diabetic macular edema [DME] and proliferative diabetic retinopathy [PDR]), which require frequent life-long follow-up, have increased hospital demands markedly. Subsequent delays in patient's evaluation and treatment are causing sight loss. Strategies to increase capacity are needed urgently. The retinopathy (EMERALD) study tested diagnostic accuracy, acceptability, and costs of a new health care pathway for people with previously treated DME or PDR. DESIGN: Prospective, multicenter, case-referent, cross-sectional, diagnostic accuracy study undertaken in 13 hospitals in the United Kingdom. PARTICIPANTS: Adults with type 1 or 2 diabetes previously successfully treated DME or PDR who, at the time of enrollment, had active or inactive disease. METHODS: A new health care pathway entailing multimodal imaging (spectral-domain OCT for DME, and 7-field Early Treatment Diabetic Retinopathy Study [ETDRS] and ultra-widefield [UWF] fundus images for PDR) interpreted by trained nonmedical staff (ophthalmic graders) to detect reactivation of disease was compared with the current standard care (face-to-face examination by ophthalmologists). MAIN OUTCOME MEASURES: Primary outcome: sensitivity of the new pathway. SECONDARY OUTCOMES: specificity; agreement between pathways; costs; acceptability; proportions requiring subsequent ophthalmologist assessment, unable to undergo imaging, and with inadequate images or indeterminate findings. RESULTS: The new pathway showed sensitivity of 97% (95% confidence interval [CI], 92%-99%) and specificity of 31% (95% CI, 23%-40%) to detect DME. For PDR, sensitivity and specificity using 7-field ETDRS images (85% [95% CI, 77%-91%] and 48% [95% CI, 41%-56%], respectively) or UWF images (83% [95% CI, 75%-89%] and 54% [95% CI, 46%-61%], respectively) were comparable. For detection of high-risk PDR, sensitivity and specificity were higher when using UWF images (87% [95% CI, 78%-93%] and 49% [95% CI, 42%-56%], respectively, for UWF versus 80% [95% CI, 69-88%] and 40% [95% CI, 34%-47%], respectively, for 7-field ETDRS images). Participants preferred ophthalmologists' assessments; in their absence, they preferred immediate feedback by graders, maintaining periodic ophthalmologist evaluations. When compared with the current standard of care, the new pathway could save £1390 per 100 DME visits and between £461 and £1189 per 100 PDR visits. CONCLUSIONS: The new pathway has acceptable sensitivity and would release resources. Users' suggestions should guide implementation.

Intra and inter-rater agreement of inflammatory choroidal neovascular membrane measurements using optical coherence tomography angiography.

PURPOSE: Automated measurement algorithm software is not routinely available in optical coherence tomography angiography (OCTA) devices and manual measurement of choroidal neovascular membrane (CNVM) size is necessary. Our aim was to determine intra- and inter-rater agreement of inflammatory CNVM manual measurements obtained with OCTA. METHODS: OCTA (Triton® Topcon Corporation) images in patients with inflammatory CNVM were imported into ImageJ software v1.50 (NIH image). Two experienced observers performed manual area and perimeter measurements independently, and one of the observers performed the same measurements twice. Agreement was evaluated with intraclass correlation coefficients (ICC) and concordance correlation coefficients (CCC). Bland-Altman plots were plotted to graphically assess concordance. Statistical analysis was performed using STATA v13.0. RESULTS: Sixteen eyes of 16 subjects, with a mean age of 39.0 ± 16.6 years (range 13-71), were included. Mean CNVM area and perimeter was 124.83 ± 117.80 and 4.20 ± 2.00 mm, respectively. Intra-rater ICC for both area and perimeter measured was 0.99 (95% confidence interval (CI) 0.99-0.99). Inter-rater ICC for area and perimeter measured was 0.95 (95%CI 0.87-0.98) and 0.81 (95%CI 0.17-0.94), respectively. Intra-rater CCC for both area and perimeter measured was 0.99 (95%CI 0.99-0.99). Inter-rater CCC for both area and perimeter measured was 0.91 (95%CI 0.81-0.99) and 0.66 (95%CI 0.44-0.88), respectively. CONCLUSIONS: Inflammatory CNVM manual measurement showed high intra-rater agreement and moderate inter-rater agreement. Repeatability and reproducibility studies are essential in manual analysis to establish thresholds that can distinguish measurements variation from true clinical change. An automatic algorithm may be helpful to accurately grade lesions and monitor disease activity and response to treatment.

Psychological and Psychosocial Interventions for Depression and Anxiety in Patients With Age-Related Macular Degeneration: A Systematic Review.

OBJECTIVE: To review the current literature on psychosocial and psychological interventions to prevent and treat depression and anxiety in patients with age-related macular degeneration (AMD). METHODS: The authors conducted a systematic review of literature evaluating psychosocial and psychological interventions for depression and anxiety in patients with AMD. Primary searches of PubMed, Cochrane library, EMBASE, Global Health, Web of Science, EBSCO, and Science Direct were conducted to include all articles published up to April 21, 2018. RESULTS: Of a total of 398 citations retrieved, the authors selected 12 eligible studies published between 2002 and 2016. The authors found nine randomized controlled trials (RCT), and three non-randomized intervention (NRI) studies. RCT studies suggested that interventions using group self-management techniques and individual behavioral activation plus low vision rehabilitation can be effective to treat and prevent depression in patients with AMD, and one study suggested that a stepped-care intervention using cognitive-behavioral techniques can be effective to manage anxiety and depression over time. NRI studies highlighted a positive effect of self-help and emotion-focused interventions to reduce depression. CONCLUSION: Clinical practice with patients with AMD can rely on some tailored cognitive-behavioral therapeutic protocols to improve patients' mental health, but further clinical trials will generate the necessary evidence-based knowledge to improve those therapeutic techniques and offer additional tailored interventions for patients with AMD.

Treatment decisions of UK hospital optometrists and ophthalmologists in patients with nAMD: a vignette study.

PURPOSE: A vignette study to examine treatment decisions made by UK hospital optometrists in patients with neovascular age-related macular degeneration (nAMD) and the effect of optometrists' experience on agreement. METHODS: Patients with nAMD attending Manchester Royal Eye Hospital, Manchester, UK were identified as potential candidates for the case series of vignettes. The cases were chosen to reflect a varied case-mix with respect to difficulty as well as ensuring good quality of the images. Each vignette included a history summary consisting of the number of previous injections given and visual acuity measurements at baseline, the previous visit, and the current visit. Images were compiled to show baseline fundus photographs and ocular coherence tomography (OCT) images with the current visit images on which the treatment decision was to be made along with the images from the previous visit. Hospital optometrists were recruited and asked to complete the series of vignettes, deciding if treatment was required at that visit and how confident they felt with that decision. Their responses were compared to the reference standard created by a consensus of consultant ophthalmologists with a sub-speciality interest in medical retina. RESULTS: Regarding treatment decision for optometrists, the percentage correct value was 75% with the sensitivity being 75.6% (95% CI 70.1-80.3) and the specificity as 75.1% (95% CI 72.1-77.8). No statistically significant difference was found between differing levels of experience. However, there was a significant difference in confidence levels between groups. Potentially sight threatening decisions accounted for 6.4% of the optometrists' decisions, 3.5% were made with a high confidence rating suggesting no discussion with an ophthalmologist was required. CONCLUSIONS: Although the optometrists showed modest agreement with the reference standard in a series of cases that have higher than average complexity, the optometrists showed a similar amount of variability within their treatment decisions compared to the reference standard. The optometrists were therefore not inferior in their performance compared to the ophthalmologists and this can be seen as supporting evidence for their extended role within this clinical area. Experience did not have an effect on 'correct' treatment decisions although there was a statistically significant effect on increasing confidence of treatment decision.

Swept-source optical coherence tomography angiography features of sub-retinal fibrosis in neovascular age-related macular degeneration.

IMPORTANCE: The study highlights the role of optical coherence angiography in the management of patients with neovascular age-related macular degeneration (nAMD) who have developed sub-retinal fibrosis. BACKGROUND: Development of sub-retinal fibrosis in the context of nAMD is known to adversely affect visual function. The aim of this study is to assess structure and flow features obtained through swept-source optical coherence tomography angiography (OCTA) in patients with sub-retinal fibrosis and associate these with visual acuity (VA). DESIGN: Institutional retrospective cohort study. PARTICIPANTS: A total 39 eyes of 39 patients with nAMD with sub-retinal fibrosis imaged with OCTA were included in this study. METHODS: Patients underwent swept-source OCTA. Thickness of sub-retinal hyper-reflective material (SHRM) and presence and configuration of a choroidal neovascular membrane were recorded in each case. MAIN OUTCOME MEASURES: A univariate multiple regression was performed seeking associations between VA and structural and flow OCTA features. RESULTS: Average VA on the date of OCTA was 53 ± 22 ETDRS letters. Average thickness of centre-involving SHRM was 157 ± 73 µm. A choroidal neovascular membrane was detectable in 26 cases and not detectable in 13. VA was independently influenced by thickness of SHRM (P = 0.034) and presence of a detectable choroidal neovascular membrane (P = 0.02) on OCTA. CONCLUSIONS AND RELEVANCE: Poorer VA in patients with nAMD and sub-retinal fibrosis is associated with presence of a detectable neovascular membrane on OCTA. The role of OCTA to guide nuanced management decisions in this patient population may be significant.

QUANTITATIVE ANALYSIS OF PIGMENT EPITHELIAL DETACHMENT RESPONSE TO DIFFERENT ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR AGENTS IN WET AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To assess whether best-corrected visual acuity and pigment epithelial detachment (PED) height, volume, and reflectivity in patients with wet age-related macular degeneration are influenced by baseline anatomical and functional parameters, including quantifiable metrics of PED morphology and choice of treatment. METHODS: One hundred two consecutive, treatment-naive wet age-related macular degeneration patients with PED (>50 µm) treated with aflibercept (52) or ranibizumab (50) were retrospectively included. Pigment epithelial detachment height, horizontal and vertical dimensions, and volume were recorded at baseline, 3 months, and 1 year, respectively. Bespoke image analysis software provided a quantifiable measure of reflectivity. RESULTS: Best-corrected visual acuity at 3 months was influenced by baseline best-corrected visual acuity (P = 0.006). Pigment epithelial detachment height was influenced by baseline height (P = 0.009), subretinal fluid (P = 0.008), central macular thickness (P = 0.006), and use of aflibercept (P = 0.003) at 3 months and by baseline height (P = 0.018), volume (P = 0.017), vertical dimension (P = 0.0004), and aflibercept (P = 0.015) at 1 year. Pigment epithelial detachment reflectivity increased from 43.59 to 55.86 (3 months) and 57.35 (1 year) (P < 0.001) and was influenced by its baseline values and, interestingly, use of aflibercept at 3 months (P = 0.013). CONCLUSION: Quantifiable metrics of PED morphology improve with treatment, and PED content becomes hyperreflective, more so on aflibercept. Pigment epithelial detachments respond better in the context of more active disease. More hyporeflective PED content may predispose to better treatment response, especially with aflibercept.

Psychological impact of anti-VEGF treatments for wet macular degeneration-a review.

PURPOSE: To review the current literature on the psychological impact of anti-VEGF treatments for wet age-related macular degeneration (wAMD), in terms of patients' experiences of receiving these treatments, and the impact of these treatments for patients' mental health and quality of life. METHODS: We critically analyzed current literature evaluating psychological impact of anti-VEGF treatments for wAMD. Primary searches of PubMed, Science Direct, and Web of Science were conducted in July and August of 2015. We reviewed all papers on the topic published until August 5, 2015. RESULTS: Our literature search found 14 papers addressing the psychological impact of anti-VEGF treatments for wAMD. Results highlighted potential anxieties and experiences of pain caused by receiving regular intravitreal injections. A positive visual outcome of anti-VEGF therapy is associated with positive vision-related QOL outcomes, although such association seems to be dependent on improvements on visual acuity. In the literature reviewed, patients receiving anti-VEGF treatments showed a prevalence rate of depression between 20 and 26 %. CONCLUSIONS: Although anti-VEGF treatments can cause some anxiety and being experienced as a stressful event, especially in the beginning of the treatment, preliminary findings suggest a potential benefit for long-term vision-related quality of life. Further longitudinal and qualitative research should bring more evidence on the positive and negative effects of these treatments on patients' long-term mental health.

Development and testing of an automated computer tablet-based method for self-testing of high and low contrast near visual acuity in ophthalmic patients.

PURPOSE: Many eye diseases require on-going assessment for optimal management, creating an ever-increasing burden on patients and hospitals that could potentially be reduced through home vision monitoring. However, there is limited evidence for the utility of current applications and devices for this. To address this, we present a new automated, computer tablet-based method for self-testing near visual acuity (VA) for both high and low contrast targets. We report on its reliability and agreement with gold standard measures. METHODS: The Mobile Assessment of Vision by intERactIve Computer (MAVERIC) system consists of a calibrated computer tablet housed in a bespoke viewing chamber. Purpose-built software automatically elicits touch-screen responses from subjects to measure their near VA for either low or high contrast acuity. Near high contrast acuity was measured using both the MAVERIC system and a near Landolt C chart in one eye for 81 patients and low contrast acuity using the MAVERIC system and a 25 % contrast near EDTRS chart in one eye of a separate 95 patients. The MAVERIC near acuity was also retested after 20 min to evaluate repeatability. RESULTS: Repeatability of both high and low contrast MAVERIC acuity measures, and their agreement with the chart tests, was assessed using the Bland-Altman comparison method. One hundred and seventy-three patients (96 %) completed the self- testing MAVERIC system without formal assistance. The resulting MAVERIC vision demonstrated good repeatability and good agreement with the gold-standard near chart measures. CONCLUSIONS: This study demonstrates the potential utility of the MAVERIC system for patients with ophthalmic disease to self-test their high and low contrast VA. The technique has a high degree of reliability and agreement with gold standard chart based measurements.

Routine versus As-Needed Bevacizumab with 12-Weekly Assessment Intervals for Neovascular Age-Related Macular Degeneration: 92-Week Results of the GMAN Trial.

PURPOSE: To evaluate the efficacy and safety of intravitreal bevacizumab (Avastin; Genentech, South San Francisco, CA) in patients with neovascular age-related macular degeneration (nAMD) using 2 different treatment regimens in which patients were assessed clinically at up to 12-week intervals. DESIGN: Randomized, controlled, noninferiority trial. PARTICIPANTS: A total of 331 patients with nAMD. METHODS: Patients were treated with 1.25 mg intravitreal bevacizumab and followed up to 92 weeks. They were randomized into 2 arms. All patients received 3 loading doses 4 weeks apart and thereafter were assessed every 12 weeks until the end of the study. One arm received a routine treatment at each 12-week assessment, and the other arm was treated at these assessments on an as-needed basis. After the loading doses, patients in either arm who showed signs of disease activity had an additional assessment after 6 weeks and at that visit had top-up treatments on an as-needed basis. MAIN OUTCOME MEASURES: Mean best-corrected visual acuity (BCVA) at 92 weeks. RESULTS: At 92 weeks, patients who had treatments every 12 weeks had superior BCVA to those treated on an as-needed basis every 12 weeks (P = 0.008), with the regular treatment arm gaining a mean BCVA of 5.5 letters and the as-needed treatment arm gaining 0.6 letters. The regular treatment arm of the study showed significantly improved outcomes with respect to 5-, 10-, and 15-letter changes in BCVA from baseline compared with the as-needed treatment arm, as well as superior reading speed. In patients who completed the study, up to but not including week 92, the mean number of treatments was 10.8 for the regular treatment arm and 9.1 for the as-needed treatment arm. CONCLUSIONS: A treatment regimen with regular bevacizumab injections every 12 weeks after loading doses supplemented with as-needed top-up treatments produced a stable improvement in BCVA from baseline. The improvement in BCVA was broadly similar to that obtained in other studies using anti-vascular endothelial growth factor drugs with more frequent assessments and treatments.

Omega-3 Fatty Acids and Age-Related Macular Degeneration.

Against a background of considerable epidemiological and other evidence implicating omega-3 fatty acids in the prevention of age-related macular degeneration (AMD), the negative results of the Age-Related Disease Study 2 (AREDS2) were unexpected. The possibility that the design, setting, intake or subjects of AREDS2 may not have permitted the prophylactic potential of omega-3 to be adequately demonstrated is considered. Epidemiological studies had indicated potential preventative effects of omega-3, and an earlier randomised prospective study (NAT2) showed that patients who achieved high red blood cell membrane EPA/DHA (eicosapentaenoic acid/docosahexaenoic acid) levels were significantly protected against AMD compared with those with permanently low EPA/DHA levels. Various methodological differences between these studies are considered. NAT2 included a true placebo group, whereas control subjects in AREDS2 received a nutritional formula already found to be effective in AREDS1, but no placebo for DHA/EPA supplementation. Differences in the handling of non-compliant subjects and the formulation of the test formulations are considered. Given these considerations, and other lines of evidence from laboratory and clinical studies, closing the chapter on omega-3 in AMD prevention may be premature.

The association between dark adaptation and macular pigment optical density in healthy subjects.

PURPOSE: To investigate whether macular pigment optical density (MPOD) is related to dark adaptation in healthy subjects. METHODS: Dark adaptation was measured after a minimum 30 % pigment bleach in 33 subjects (aged 15-68), using a white 1° stimulus presented 11° below fixation on a cathode ray tube monitor. The luminance range of the monitor was extended using neutral density filters. A heterochromatic flicker photometry based instrument (MPS 9000) was used to measure MPOD. RESULTS: The average MPOD for the whole group was 0.37 ± 0.21 optical density units. Subjects with lighter irides had on average 40 % lower MPOD compared to those with darker irides (0.3 ± 0.20 vs 0.5 ± 0.19). Group mean MPOD was weakly associated with second (r = 0.32, p = 0.07) and third rod-mediated recovery rates (r = 0.31, p = 0.08) and with the rod threshold (r = -0.24, p = 0.18) 30 min after the onset of bleach. MPOD was unrelated to cone time constant (r = -0.02, p = 0.91), cone threshold (r = -0.01, p = 0.96), rod-cone break (r = 0.13, p = 0.45) or the rod-rod break (r = 0.11, p = 0.52). The second rod-mediated recovery rate (S2) for the lower 10th percentile of MPOD (n = 4) was 0.18 log cd.m(-2).min(-1) and 0.24 log cd.m(-2).min(-1) for the upper 10th percentile (n = 4). The two groups were significantly different (t = -2.67, p = 0.037). CONCLUSIONS: We report a statistically significant difference between subjects falling in the 10th percentile extremes of MPOD and rod-mediated but not cone-mediated sensitivity recovery. Further investigation into the relationship between MPOD and rod function is warranted, particularly extending the work to encompass those with low MPOD and poor night vision.