OPTICAL COHERENCE TOMOGRAPHY FEATURES OF POLYPOIDAL LESION CLOSURE IN POLYPOIDAL CHOROIDAL VASCULOPATHY TREATED WITH AFLIBERCEPT.

PURPOSE: To evaluate whether optical coherence tomography (OCT) can determine polypoidal lesion (PL) perfusion in polypoidal choroidal vasculopathy eyes after 12 months of aflibercept monotherapy. Polypoidal lesion perfusion status, assessed by indocyanine green angiography, is an important anatomical outcome in polypoidal choroidal vasculopathy management. METHODS: Post hoc data from a prospective randomized, open-label, study in eyes with polypoidal choroidal vasculopathy undergoing monotherapy with aflibercept evaluated PL perfusion status based on indocyanine green angiography (gold standard) and OCT features from baseline to 12 months. RESULTS: Individual PLs (110 in total) from 48 eyes (48 patients) showed at 12 months; 57/110 PLs (51.8%) were closed on indocyanine green angiography. At 12 months, eyes with closed PLs were more likely to have the following OCT features: 1) no subretinal fluid (67.1% vs. 32.9%), 2) smaller pigment epithelial detachment height (67.2 [±43.8] vs. 189.2 [±104.9] µm), 3) densely hyperreflective pigment epithelial detachment contents (84.0% vs. 16.0%), 4) an absence of a hyperreflective ring(64.0% vs. 36.0%), and a 5) indistinct overlying retinal pigment epithelial (71.4% vs. 28.6%) (all P < 0.05). The three highest performing OCT features that differentiated perfused from closed PLs were (1), (3), and (4) (area under the receiver operating characteristic curve 0.85, 0.73, and 0.70, respectively). A combination of these three features achieved an area under the receiver operating characteristic curve of 0.90. CONCLUSION: Polypoidal lesion closure, an important anatomical treatment outcome in polypoidal choroidal vasculopathy typically defined by indocyanine green angiography, can be accurately detected by specific OCT features.

The Differential Impact of Age on Vision-Related Quality of Life across the Visual Impairment Spectrum.

PURPOSE: Visual impairment (VI) can have a detrimental impact on vision-related quality of life (VRQoL), but it is still unclear how this relationship varies with age across the VI spectrum. We determined the age-stratified, cross-sectional, and longitudinal associations between VI severity and VRQoL. DESIGN: The baseline and follow-up Singapore Chinese Eye Studies (SCES-1/-2; 2009-2011 and 2015-2017). PARTICIPANTS: A total of 3068 SCES-1 participants (mean age [standard deviation {SD}]: 59.5 [9.8] years; 50.2% female) and 1919 SCES-2 participants (mean age [SD]: 56.8 [8.3] years; 49.9% female). METHODS: Visual impairment was defined as visual acuity (VA) of > 0.3 logarithm of the minimum angle of resolution (logMAR) units; VI severity as mild-moderate (logMAR scores less than the median of all individuals with VI) and severe (logMAR scores median or greater); and VI incidence as VI absence at baseline, but evident at follow-up. Age was stratified into 40 to 49 years, 50 to 64 years, and ≥65 years. MAIN OUTCOME MEASURES: Rasch-transformed scores from the 32-item Impact of Visual Impairment (IVI) questionnaire were used to measure the "Reading," "Mobility," and "Emotional" domains of VRQoL. Multiple linear regression models determined the age-stratified associations of prevalent and incident VI with all 3 VRQoL outcomes, adjusted for potential confounders. RESULTS: Of the 807 persons with prevalent VI, 55.9% had mild-moderate and 44.1% had severe VI. Compared with no VI, age-stratified analyses showed that VRQoL decrements were significant only in the older age groups (mild-moderate VI: 6.2% and 8.1% reduction in Mobility and Reading scores in those aged ≥ 65 years; severe VI: 8.5% to 13.4% reductions in the 3 VRQoL scores in those aged ≥ 50 years). This interaction with older age became more pronounced with incident VI (N = 168), where decrements in all 3 VRQoL domains were evident only in those aged ≥65 years compared with persons without incident VI. CONCLUSIONS: Our results suggest that the VI-VRQoL associations are driven mainly by older individuals aged ≥65 years, highlighting the need for effective regular screening and early intervention modalities to prevent the presence and onset of VI, and subsequent VRQoL declines, in these individuals.

Prevalence, determinants and association of unawareness of diabetes, hypertension and hypercholesterolemia with poor disease control in a multi-ethnic Asian population without cardiovascular disease.

BACKGROUND: To explore the prevalence and determinants of unawareness of diabetes, hypertension and hypercholesterolemia and its association with poor disease control in a multi-ethnic Asian population without cardiovascular disease (CVD). METHODS: We included 6904 Chinese, Malay and Indian individuals (mean age [SD] 58.2 [10.2] years; 52.6% female) with diabetes, hypertension and/or hypercholesterolemia from the cross-sectional population-based Singapore Epidemiology of Eye Diseases study (2004-2011). Diabetes was defined as random blood glucose ≥ 11.1 mmol/L or HbA1c > 6.5% or self-reported use of diabetes medication; hypertension as systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg or self-reported use of anti-hypertensive treatment; and hypercholesterolemia as total cholesterol ≥ 6.2 mmol/L or self-reported use of lipid-lowering medications. Unawareness was based on participants' answers to the questions: "Did your medical practitioner ever tell you that you have diabetes/hypertension/high cholesterol?" The determinants of unawareness, and its association with poor disease control, were assessed using multivariable binary logistic regression models adjusted for known potential confounders. RESULTS: Of the 2380 (34.5%), 5386 (78.0%) and 3607 (52.2%) with diabetes, hypertension and hypercholesterolemia, respectively, unawareness rates were 30.7%, 43.1% and 40.9%, respectively. Having a higher BMI, particularly if obese, and Malay ethnicity were associated with greater unawareness of diabetes; Malay and Indian ethnicities and current smoking with greater unawareness of hypertension; and education ≤6 years, current smoking, and blue collar jobs or unemployment with greater unawareness of hypercholesterolemia (all P < 0.05). Lack of awareness of each condition was independently associated with poorer disease control in the case of hypertension and hypercholesterolemia, while the converse was true for diabetes (all P < 0.05). CONCLUSIONS: Unawareness of diabetes, hypertension, or hypercholesterolemia is high in Singapore, with risk factors varying across all three diseases, although Malay ethnicity is a consistent one. Unawareness was also associated with poor management for hypertension and hypercholesterolemia. Public health education and screening programs should target at-risk individuals, especially Malays, to reduce the likelihood of incident CVD.

Interpretation of hip fracture patterns using areal bone mineral density in the proximal femur.

INTRODUCTION: Bone mineral density scans are currently interpreted based on an average score of the entire proximal femur. Improvements in technology now allow us to measure bone density in specific regions of the proximal femur. The study attempts to explain the pathophysiology of neck of femur (NOF) and intertrochanteric/basi-cervical (IT) fractures by correlating areal BMD (aBMD) scores with fracture patterns, and explore possible predictors for these fracture patterns. MATERIALS AND METHODS: This is a single institution retrospective study on all patients who underwent hip surgeries from June 2010 to August 2012. A total of 106 patients (44 IT/basi-cervical, 62 NOF fractures) were studied. The data retrieved include patient characteristics and aBMD scores measured at different regions of the contralateral hip within 1 month of the injury. Demographic and clinical characteristic differences between IT and NOF fractures were analyzed using Fisher's Exact test and two-sample t test. Relationship between aBMD scores and fracture patterns was assessed using multivariable regression modeling. RESULTS: After adjusted multivariable analysis, T-Troc and T-inter scores were significantly lower in intertrochanteric/basi-cervical fractures compared to neck of femur fractures (P = 0.022 and P = 0.026, respectively). Both intertrochanteric/basi-cervical fractures (mean T.Tot -1.99) and neck of femur fractures (mean T.Tot -1.64) were not found to be associated with a mean T.tot less than -2.5. However, the mean aBMD scores were consistently less than -2.5 for both intertrochanteric/basi-cervical fractures and neck of femur fractures. Gender and calcium intake at the time of injury were associated with specific hip fracture patterns (P = 0.002 and P = 0.011, respectively). CONCLUSIONS: Hip fracture patterns following low energy trauma may be influenced by the pattern of reduced bone density in different areas of the hip. Intertrochanteric/basi-cervical fractures were associated with significantly lower T-Troc and T-Inter scores compared to neck of femur fractures, suggesting that the fracture traversed through the areas with the lowest bone density in the proximal femur. In the absence of reduced T.Troc and T.Inter, neck of femur fractures occurred more commonly. T-Total scores may underestimate the severity of osteoporosis/osteopenia and measuring T-score at the neck of femur may better reflect the severity of osteoporosis and likelihood of a fragility fracture.

Relationship between vision impairment and employment.

AIMS: To examine the relationship between vision impairment (VI) and employment outcomes in a multiethnic Asian population. METHODS: We included 7608 Asian individuals aged ≥40 years (mean (SD) age: 58.4 (10.3) years; 64.8% male) from the Singapore Epidemiology Eye Disease Study (response rate: 78.8%), a population-based cohort study (mean follow-up period: 6.2 years). Presenting visual acuity (VA) was assessed using a logarithm of the minimum angle of resolution (logMAR) chart, with VI defined as mild (VA >0.3 to <0.6 logMAR) and moderate to severe (VA ≥0.6 logMAR). Self-reported employment statuses at both baseline and follow-up were used as outcomes. Underemployment was defined as a decline in occupational skill level, categorised by International Standard Classification of Occupations, at follow-up compared with baseline. Multinomial logistic regression models were used to determine independent associations between VI and various employment outcomes, adjusted for variables that were found to significantly differ across employment statuses. RESULTS: Presenting VI was prevalent in 20.2% (N=1536) of participants. Compared with those without VI, participants with mild and moderate to severe VI were more likely to be unemployed at baseline (OR 1.47, 95% CI 1.15 to 1.87, p=0.002 and 2.74, 95% CI 1.94 to 3.89, p<0.001, respectively). At follow-up, participants with any VI at baseline were more likely to be underemployed (OR 1.46, 95% CI 1.03 to 2.05, p=0.033). CONCLUSION: VI, even when mild, is associated with unemployment and underemployment. Future studies should investigate whether visual interventions could be used as part of a multipronged strategy to improve employment outcomes for the population.

Combining retinal and choroidal microvascular metrics improves discriminative power for diabetic retinopathy.

PURPOSE: To use optical coherence tomography angiography (OCTA) parameters from both the retinal and choroidal microvasculature to detect the presence and severity of diabetic retinopathy (DR). METHOD: This is a cross-sectional case-control study. OCTA parameters from retinal vasculature, fovea avascular zone (FAZ) and choriocapillaris were evaluated from 3×3 mm2 fovea-centred scans. Areas under the receiver operating characteristic (ROC) curve were used to compare the discriminative power on the presence of diabetes mellitus (DM), the presence of DR and need for referral: group 1 (no DM vs DM no DR), group 2 (no DR vs any DR) and group 3 (non-proliferative DR (NPDR) vs proliferative DR (PDR)). RESULTS: 35 eyes from 27 participants with no DM and 132 eyes from 75 with DM were included. DR severity was classified into three groups: no DR group (62 eyes), NPDR (51 eyes), PDR (19 eyes). All retinal vascular parameters, FAZ parameters and choriocapillaris parameters were strongly altered with DR stages (p<0.01), except for the deep plexus FAZ area (p=0.619). Choriocapillaris parameters allowed to better discriminate between no DM versus DM no DR group compared with retinal parameters (areas under the ROC curve=0.954 vs 0.821, p=0.006). A classification model including retinal and choroidal microvasculature significantly improved the discrimination between DR and no DR compared with each parameter separately (p=0.029). CONCLUSIONS: Evaluating OCTA parameters from both the retinal and choroidal microvasculature in 3×3 mm scans improves the discrimination of DM and early DR.

Knowledge, attitudes and practices towards COVID-19 among multiethnic elderly Asian residents in Singapore: a mixed-methods study.

Introduction: We investigated the knowledge, attitudes and practice (KAP) towards coronavirus disease 2019 (COVID-19) and its related preventive measures in Singaporeans aged ≥60 years. Methods: This was a population-based, cross-sectional, mixed-methods study (13 May 2020-9 June 2020) of participants aged ≥ 60 years. Self-reported KAP about ten symptoms and six government-endorsed preventive measures related to COVID-19 were evaluated. Multivariable regression models were used to identify sociodemographic and health-related factors associated with KAP in our sample. Associations between knowledge/attitude scores and practice categories were determined using logistic regression. Seventy-eight participants were interviewed qualitatively about the practice of additional preventive measures and data were analysed thematically. Results: Mean awareness score of COVID-19 symptoms was 7.2/10. The most known symptom was fever (93.0%) and the least known was diarrhoea (33.5%). Most participants knew all six preventive measures (90.4%), perceived them as effective (78.7%) and practised 'wear a mask' (97.2%). Indians, Malays and participants living in smaller housing had poorer mean scores for knowledge of COVID-19 symptoms. Older participants had poorer attitudes towards preventive measures. Compared to Chinese, Indians had lower odds of practising three out of six recommendations. A one-point increase in score for knowledge and attitudes regarding preventive measures resulted in higher odds of always practising three of six and two of six measures, respectively. Qualitative interviews revealed use of other preventive measures, for example, maintaining a healthy lifestyle. Conclusions: Elderly Singaporeans displayed high levels of KAP about COVID-19 and its related preventive measures, with a positive association between levels of knowledge/attitude and practice. However, important ethnic and socioeconomic disparities were evident, indicating that key vulnerabilities remain, which require immediate attention.

Association of macular and choroidal perfusion with long-term visual outcomes after macula-off rhegmatogenous retinal detachment.

BACKGROUND/AIMS: To examine the relationship between macular perfusion, as assessed using optical coherence tomography angiography (OCTA), and long-term visual outcome after surgical repair of macula-off rhegmatogenous retinal detachment (RRD). METHODS: A prospective study of 29 patients who had undergone successful surgical repair of macula-off RRD. OCTA imaging was performed at month 3 and repeated at months 6 and 12 after surgery. Associations between OCTA parameters including, foveal avascular zone (FAZ) area, vessel density (VD) in the superficial capillary plexus (SCP) and deep capillary plexus (DCP), choriocapillaris flow deficit features and logMAR best-corrected visual acuity (VA) were assessed using a random intercept hybrid linear mixed model. RESULTS: Over the 1-year follow-up, VA improved (0.025 logMAR/ month, 95% CI 0.015 to 0.035) and FAZ area decreased (-0.020 mm2/month, 95% CI -0.032 to -0.007). Better VA after surgery was significantly associated with denser superficial VD (ß=0.079, 95% CI 0.026 to 0.131), lower number of choriocapillaris flow deficits (ß=-0.087, 95% CI -0.154 to -0.021) and larger average size of choriocapillaris flow deficits (ß=0.085, 95% CI 0.022 to 0.147), after adjusting for baseline VA, types of surgery and other factors. CONCLUSIONS: OCTA measures of vascular perfusion in the macula may provide new pathophysiological insights and prognostic information related to macula-off RRD.

Impact of incident age-related macular degeneration and associated vision loss on vision-related quality of life.

BACKGROUND: We examined the associations between the 6-year incidence of age-related macular degeneration (AMD) and vision-related quality of life (VRQoL), and the contribution of presenting visual acuity (VA), in an Asian population. METHODS: Fundus images from the Singapore Chinese Eye Study, a population-based cohort study (baseline: 2009-2011; follow-up: 2015-2017), were graded using a modified Wisconsin age-related maculopathy grading system. Incident AMD was defined as no baseline AMD in both eyes and early/late AMD in the worse eye at follow-up. Presenting VA was assessed using the logarithm of the minimum angle of resolution chart at 4 m under standard lighting conditions with habitual correction. Multiple linear regression models determined the associations between AMD incidence with changes in the Rasch-transformed scores of the Reading, Mobility and Emotional VRQoL domains of the 32-item Impact of Visual Impairment (IVI-32) questionnaire, adjusted for traditional confounders. The contribution of presenting VA to changes in VRQoL was also estimated. RESULTS: Of the 2251 participants without AMD at baseline (mean age (SD): 57.7 (9) years, 51.4% women), 101 (4.5%) and 11 (0.5%) developed incident early and late AMD at follow-up, respectively. Incident late AMD was associated with significant 30.3%, 32.5% and 30.9% decrements in Reading, Mobility and Emotional IVI scores, respectively. The contribution of presenting VA ranged between 1.62% and 4.35% of the observed decrements. No significant associations were noted with incident early AMD. CONCLUSION: Incident late AMD had a substantial impact on all aspects of VRQoL, with presenting VA contributing only minimally to this longitudinal relationship.

Association of alcohol intake with incidence and progression of diabetic retinopathy.

PURPOSE: We examined the longitudinal association of baseline alcohol intake and frequency with the 6-year incidence and progression of diabetic retinopathy (DR) in a population-based cohort of Singaporean Indians. METHODS: We included 656 participants with diabetes mellitus, gradable retinal photographs from baseline (2007-2009) and follow-up (2013-2015) examinations, information on alcohol intake and other relevant data from the Singapore Indian Eye Study were included. Incident DR was defined using the Modified Airlie House Classification as no DR at baseline and at least minimal non-proliferative DR at follow-up; and DR progression as at least a one-step worsening in DR at follow-up from minimal or worse status at baseline, excluding those with proliferative DR. RESULTS: The mean age (SD) of our participants (n=656) was 58.8 (9.2) years, and 54.4% were male. At follow-up, 82 of 510 (16%) participants developed DR, and 45 of 146 (30.8%) had DR progression. 65 (12.7%) and 28 (19.1%) participants consumed alcohol in incident DR and progression categories, respectively. In multivariable analyses, those who consumed alcohol had nearly two-thirds reduced odds of incident DR (OR (95% CI): 0.36 (0.13 to 0.98)) compared with those who did not. Participants with infrequent consumption of alcohol also had a reduction in odds of incident DR (0.17 (0.04 to 0.69)), compared with non-drinkers. No association was found between alcohol consumption and DR progression. CONCLUSIONS AND RELEVANCE: In our longitudinal population of Singapore Indians, baseline alcohol intake, particularly infrequent consumption, was associated with lower risk of developing DR, compared with non-drinkers, in line with previous cross-sectional findings.

Role of socio-economic factors in visual impairment and progression of diabetic retinopathy.

BACKGROUND: To investigate the longitudinal associations between person-level and area-level socioeconomic status (PLSES and ALSES, respectively) with diabetic retinopathy (DR) and visual impairment (VI) in Asians with diabetes mellitus (DM). METHODS: In this population-based cohort study, we included 468 (39.4%) Malays and 721 (60.6%) Indians with DM, with a mean age (SD) of 58.9 (9.1) years; 50.6% were female and the mean follow-up duration was 6.2 (0.9) years. Individual PLSES parameters (education, monthly income and housing type) were quantified using questionnaires. ALSES was assessed using the Socioeconomic Disadvantage Index derived from Singapore's 2010 areal census (higher scores indicate greater disadvantage). Incident DR and VI were defined as absent at baseline but present at follow-up, while DR and VI progression were defined as a ≥1 step increase in severity category at follow-up. Modified Poisson regression analysis was used to determine the associations of PLSES and ALSES with incidence and progression of DR and VI, adjusting for relevant confounders. RESULTS: In multivariable models, per SD increase in ALSES score was associated with greater DR incidence (risk ratio (95% CI) 1.27 (1.13 to 1.44)), DR progression (1.10 (1.00 to 1.20)) and VI incidence (1.10 (1.04 to 1.16)), while lower PLSES variables were associated with increased DR (low income: 1.68 (1.21 to 2.34)) and VI (low income: 1.44 (1.13 to 1.83); ≤4 room housing: 2.00 (1.57 to 2.54)) incidence. CONCLUSIONS: We found that both PLSES and ALSES variables were independently associated with DR incidence, progression and associated vision loss in Asians. Novel intervention strategies targeted at low socioeconomic status communities to decrease rates of DR and VI are warranted.

Validation of a novel diabetic retinopathy utility index using discrete choice experiments.

BACKGROUND/AIMS: To validate a preference-based Diabetic Retinopathy Utility Index (DRU-I) using discrete choice experiment (DCE) methods and assess disutilities associated with vision-threatening DR (VTDR: severe non-proliferative DR, proliferative DR and clinically significant macular oedema) and associated vision impairment. METHODS: The DRU-I comprises five quality-of-life dimensions, including Visual symptoms, Activity limitation/mobility, Lighting and glare, Socio-emotional well-being and Inconvenience, each rated as no, some, or a lot of difficulty. The DRU-I was developed using a DCE comprising six blocks of nine choice sets which, alongside the EuroQoL-5D (EQ-5D-3L) and Vision and Quality of Life (VisQoL) utility instruments, were interviewer-administered to participants. To ensure the DRU-I was sensitive to severe disease, we oversampled patients with VTDR. Data were analysed using conditional logit regression. RESULTS: Of the 220 participants (mean±SD age 60.1±11.3 years; 70.9% men), 57 (29.1%) and 139 (70.9%) had non-VTDR and VTDR, respectively, while 157 (71.4%), 20 (9.4%) and 37 (17.3%) had no, mild or moderate/severe vision impairment, respectively. Regression coefficients for all dimensions were ordered as expected, with worsening levels in each dimension being less preferred (theoretical validity). DRU-I utilities decreased as DR severity (non-VTDR=0.87; VTDR=0.80; p=0.021) and better eye vision impairment (none=0.84; mild=0.78; moderate/severe=0.72; p=0.012) increased. DRU-I utilities had low (r=0.39) and moderate (r=0.58) correlation with EQ-5D and VisQoL utilities, respectively (convergent validity). DISCUSSION: The DRU-I can estimate utilities associated with vision-threatening DR and associated vision impairment. It has the potential to assess the cost-effectiveness of DR interventions from a patient perspective and inform policies on resource allocation relating to DR.

The relationship between pigment epithelial detachment and visual outcome in neovascular age-related macular degeneration and polypoidal choroidal vasculopathy.

BACKGROUND/OBJECTIVES: To compare the detailed optical coherence tomography (OCT)-based morphological parameters of pigment epithelial detachment (PED) in eyes presenting with neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV), and to assess whether these PED-associated parameters influence 1-year visual outcomes. SUBJECT/METHODS: We analysed images from a prospective observational study of treatment-naive Asian participants with nAMD or PCV. An independent reading centre graded baseline morphological features of PED on spectral-domain OCT, including greatest height, greatest width, greatest volume, morphology (predominantly dome shaped versus peaked), presence of retinal pigment epithelium (RPE) tear and cholesterol bands. The influence of these baseline features on 12 months best corrected visual acuity (BCVA) was evaluated. RESULTS: Seventy-eight eyes of 78 participants with PED were studied. In total, 40 (51.3%) participants had nAMD and 38 (48.7%) had PCV. Eyes with PCV, compared with nAMD, had PED of greater height (455.9 µm versus 389.9 µm; P = 0.035) and had higher prevalence of RPE tear (22.9 versus 5.3%; P = 0.041). In the multivariate analysis, only baseline BCVA was significantly associated with month 12 BCVA, but none of the PED-associated OCT parameters at baseline influenced month 12 BCVA. CONCLUSIONS: Despite the differences in PED height and prevalence of RPE tear between nAMD and PCV, none of these PED morphological factors on OCT at baseline significantly influenced visual outcome at 12 months.

Rates and Predictors of Nonadherence to Postophthalmic Screening Tertiary Referrals in Patients with Type 2 Diabetes.

Purpose: To determine the rates and develop an initial risk prediction model for nonadherence to post screening ophthalmic referral (PSOR) in type 2 diabetes mellitus (T2DM) patients attending a national diabetic retinopathy screening program in Singapore. Methods: Data from 2387 patients with T2DM (mean [standard deviation] age: 66.5 [11] years; 52.5% female patients) who underwent teleophthalmic screening between 2010 and 2014 under the Singapore Integrated Diabetic Retinopathy Program were extracted from electronic medical records. All were referred for tertiary ophthalmic management at the Singapore National Eye Centre (SNEC). Nonadherence was defined as not attending the SNEC appointment within 6 months of the assigned appointment date. Regression analysis using traditional modified Poisson and conditional inference models was used to construct and evaluate the discriminative ability of the preliminary risk prediction model to identify nonadherent individuals. Results: Nonadherence rates to PSOR was 12.7% (95% confidence interval, 11.4%-14.1%). In traditional multivariable models adjusted for sociodemographic, lifestyle, and ocular factors, nonadherent individuals had higher triglyceride levels and were less likely to have a referable eye condition (P < 0.05). This model was able to identify nonadherent individuals with an accuracy (area under the curve) of 84%. In contrast, the conditional inference model was able to achieve similar discriminative ability using only participants' ocular health characteristics. Conclusions: The rates of nonadherence to PSOR in Singaporean individuals with T2DM is low, with better ocular health being strongly predictive of nonadherence in our Asian population. Translational Relevance: Our results may inform interventions to decrease nonadherence to PSOR.

Effectiveness of an innovative and comprehensive eye care model for individuals in residential care facilities: results of the residential ocular care (ROC) multicentred randomised controlled trial.

BACKGROUND: To assess the clinical and patient-centred effectiveness of a novel residential ocular care (ROC) model in Australian individuals residing in residential care. METHODS: In this prospective, multicentred, randomised controlled trial conducted in 38 Australian aged-care facilities (2015-2017), 178 visually impaired individuals living in residential care facilities (mean age ±SD: 83.9±8.6 years; 65.7% women) were cluster randomised to ROC (n=95) or usual care (n=83) pathways. The ROC arm comprised a tailored and comprehensive within-site eye examination and care rehabilitation pathway, while usual care participants were given a referral to an external eyecare provider. Outcomes included presenting distance and near visual acuity (PNVA); Rasch-transformed Reading, Emotional and Mobility scores from the Impact of Vision Impairment questionnaire; quality of vision (QoV comprising Rasch-transformed Frequency, Severity and Bother domains) scores; Euroqol-5-Dimensions (raw scores); Cornell Scale for Depression (raw scores) and 6-month falls frequency, assessed at baseline and 6 months post intervention. Within-group and between-group comparisons were conducted using linear mixed models, adjusted for baseline differences in characteristics between the two arms. RESULTS: At 6 months, intention-to-treat analyses showed significant between-group improvements in ROC residents compared with usual care for PNVA, Emotional and QoV scores (all p<0.05) These significant findings were retained in per-protocol analyses. No other between-group changes were observed. CONCLUSION: Our ROC model was effective in improving near vision, emotional well-being and perceived burden of vision-related symptoms in residential care dwellers in Australia with vision impairment. Future studies to evaluate the cost effectiveness and implementation of ROC in Australia are warranted.

Comparison of a commercial spectral-domain OCT and swept-source OCT based on an angiography scan for measuring circumpapillary retinal nerve fibre layer thickness.

BACKGROUND/AIMS: To assess the agreement in measuring retinal nerve fibre layer (RNFL) thickness between spectral-domain (SD; Cirrus HD, Carl Zeiss Meditec, USA) optical coherence tomography (OCT) and swept-source (SS; Plex Elite 9000, Carl Zeiss Meditec) OCT using an OCT angiography (OCTA) scanning protocol. METHODS: 57 participants (12 glaucomatous, 8 ocular hypertensive and 74 normal eyes) were scanned with two OCT instruments by a single experienced operator on the same day. Circumpapillary RNFL thicknesses were automatically segmented for SD-OCT and manually segmented for SS-OCTA scans. Agreement of global RNFL thickness, as well as average thickness in four quadrants was assessed using intraclass correlation coefficients (ICCs). RESULTS: There was excellent agreement in the inferior and superior quadrants and the global (all ICC >0.90), followed by good agreement in the temporal (ICC=0.79) and nasal (ICC=0.73) quadrants. The ICC values were similar in the subgroups except within the ocular hypertension group, where the nasal quadrant was less agreeable (ICC=0.31). SS-OCTA-derived RNFL thickness was on average 3 µm thicker than SD-OCT, particularly in the nasal (69.7±11.5 µm vs 66.3±9.3 µm; p<0.001) and temporal (75.6±13.7 µm vs 67.9±12.3 µm; p<0.001) quadrants. CONCLUSIONS: RNFL measurements taken with SS-OCTA have good-to-excellent agreement with SD-OCT, which suggests that the RNFL thickness can be sufficiently extracted from wide-field OCTA scans.

Is Sensory Loss an Understudied Risk Factor for Frailty? A Systematic Review and Meta-analysis.

BACKGROUND: Age-related sensory loss and frailty are common conditions among older adults, but epidemiologic research on their possible links has been inconclusive. Clarifying this relationship is important because sensory loss may be a clinically relevant risk factor for frailty. METHODS: In this systematic review and meta-analysis, we searched 3 databases for observational studies investigating 4 sensory impairments-vision (VI), hearing (HI), smell (SI), and taste (TI)-and their relationships with frailty. We meta-analyzed the cross-sectional associations of VI/HI each with pre-frailty and frailty, investigated sources of heterogeneity using meta-regression and subgroup analyses, and assessed publication bias using Egger's test. RESULTS: We included 17 cross-sectional and 7 longitudinal studies in our review (N = 34,085) from 766 records. Our cross-sectional meta-analyses found that HI and VI were, respectively, associated with 1.5- to 2-fold greater odds of pre-frailty and 2.5- to 3-fold greater odds of frailty. Our results remained largely unchanged after subgroup analyses and meta-regression, though the association between HI and pre-frailty was no longer significant in 2 subgroups which lacked sufficient studies. We did not detect publication bias. Longitudinal studies largely found positive associations between VI/HI and frailty progression from baseline robustness, though they were inconclusive about frailty progression from baseline pre-frailty. Sparse literature and heterogenous methods precluded meta-analyses and conclusions on the SI/TI-frailty relationships. CONCLUSIONS: Our meta-analyses demonstrate significant cross-sectional associations between VI/HI with pre-frailty and frailty. Our review also highlights knowledge gaps on the directionality and modifiability of these relationships and the impact of SI/TI and multiple sensory impairments on frailty.

Selective laser trabeculoplasty versus topical medication as initial glaucoma treatment: the glaucoma initial treatment study randomised clinical trial.

BACKGROUND/AIMS: To determine if selective laser trabeculoplasty (SLT) is superior to topical medication as a first-line treatment for glaucoma on quality of life (QoL) and clinical outcomes. METHODS: In this international, longitudinal, multisite randomised controlled trial, treatment naïve mild-to-moderate primary open angle or exfoliation glaucoma patients were randomised 1:1 to SLT or topical medication. Glaucoma-specific QoL (primary outcome) was measured using the Glaucoma Outcomes Assessment Tool (GOAT; 342 items, 12 domains). Secondary outcomes included rate of successful intraocular pressure (IOP) reduction (>25% reduction from baseline) and presence of ocular surface disease including conjunctival hyperaemia and eyelid erythema. Our intention-to-treat analysis was performed at months 12 and 24. RESULTS: Of 167 enrolled patients, 83 and 84 were randomised to SLT and topical medication, respectively; and 145 (n=75 SLT, n=70 medication) completed 24-month follow-up. While both treatment arms achieved significant within-group gains in GOAT outcomes at both endpoints, SLT patients reported a greater between-group improvement in 'social well-being' compared with medication patients (mean±SE=0.28±0.13; p=0.034) at 24 months. At month 24, the rate of successful IOP reduction was 18.6% (95% CI 3.0% to 34.3%, p=0.022) higher (absolute difference) in the medication compared with SLT group. More individuals in the medication group had conjunctival hyperaemia and eyelid erythema compared with SLT at 24 months. CONCLUSION: Overall, we did not find evidence that SLT was superior to medication in improving glaucoma-specific QoL. While we found superior IOP reduction in the medication arm, eyelid erythema and conjunctival hyperaemia were more prevalent in these patients compared with the SLT group. TRIAL REGISTRATION: ACTRN12611000720910.

Association between diabetic retinopathy and incident cognitive impairment.

BACKGROUND/AIM: The relationship between diabetic retinopathy (DR) and cognitive impairment (CI) is unclear due to equivocal findings from cross-sectional studies and a lack of long-term data. In this population-based cohort study, we investigated the longitudinal association between the severity of DR and the incidence of CI. METHODS: 682 participants with diabetes, gradable retinal photographs and no CI at baseline 2004-2011) and complete relevant data at follow-up 2010-2016 from the Singapore Epidemiology of Eye Disease Study were included. CI was assessed using the validated Abbreviated Mental Test (AMT), defined as scores of ≤6 and ≤8 for those with 0-6 and >6 years of formal education, respectively. Six-year incident CI was defined as having no CI at baseline but present at the follow-up visit. RESULTS: Of the 682 included participants, 483 (70.8%) had no DR and 199 (29.2%) had any DR. Of those with DR, 142 (20.8%) had minimal/mild DR and 57 (8.4%) had moderate or worse DR at baseline. At the follow-up visit, 40 (5.9%) participants had incident CI based on AMT. In multivariate analysis compared with participants without DR, those with any DR had more than twofold increased odds of incident CI (OR (95% CI): 2.32 (1.07 to 5.03)). Participants with moderate or worse DR had threefold increased odds of developing CI (3.41 (1.06 to 11.00)), compared with those with no DR. CONCLUSIONS: DR, particularly at the more severe stages, is associated with increased risk of developing CI, independent of vision and other risk factors.

Beyond vision loss: the independent impact of diabetic retinopathy on vision-related quality of life in a Chinese Singaporean population.

BACKGROUND/AIMS: To assess the independent impact of diabetic retinopathy (DR) on three domains of vision-related quality of life (VRQoL) in a Chinese Singapore population. METHODS: The Singapore Chinese Eye Study (n=3353; 2009-2011) was a population-based, prospective, cross-sectional study conducted at the Singapore Eye Research Institute. The study population included 292 adults with diabetes, with and without DR. DR (better eye) was categorised as presence and absence of any DR; severity of DR (no vision-threatening DR (VTDR); severe non-proliferative DR (NPDR); PDR and/or clinically significant macular oedema and VTDR). Our main outcome was VRQoL which was measured using Rasch-calibrated scores from the 'Reading', 'Mobility' and 'Emotional' domains of the Impact of Vision Impairment questionnaire. The relationship between DR and VRQoL was assessed using multiple linear regression models. RESULTS: Of the 292 individuals (mean age 61.35 ± 9.66 years; 55.8% male), 201 (68.8%), 49 (16.8%), 20 (6.8%), 22 (7.5%) and 27 (9.2%) had no DR, minimal-mild NPDR, moderate-severe NPDR, PDR and VTDR, respectively. Any DR and VTDR were independently associated with 6% and 12% worse Reading scores and 7% and 18% poorer Emotional well-being, respectively, compared with those without DR. These associations persisted after separate adjustment for visual impairment and presenting visual acuity. No significant difference was found in the Mobility domain between persons with and without DR. CONCLUSIONS: We documented that DR, particularly VTDR, was independently associated with restrictions in Reading and Emotional well-being. Understanding factors underlying the detrimental DR-VRQoL relationship may optimise rehabilitation outcomes for individuals with DR.