Shortest Distance From Fovea to Subfoveal Hemorrhage Border Is Important in Patients With Neovascular Age-related Macular Degeneration.

PURPOSE: To identify factors influencing visual outcome in patients with neovascular age-related macular degeneration (NVAMD) and subfoveal hemorrhage (SFH) treated with anti-vascular endothelial growth factor (VEGF) agents. DESIGN: Retrospective case series. METHODS: Anti-VEGF-treated eyes with SFH > 1 disc area (DA) were identified (n = 16) and changes in visual acuity (VA) and central subfield thickness (CST) from baseline to last follow-up, along with SFH area, thickness, minimum distance from fovea to SFH border, and time to resolution, were determined. RESULTS: At baseline, mean (± standard error of the mean) size and thickness of SFH were 14.9 ± 2.8 DA and 386.6 ± 46.9 µm, and mean Snellen VA and CST were 20/250 and 591.7 ± 57.0 µm. Median follow-up was 47.6 months. While more than 50% of patients had VA ≤ 20/200 at baseline and all time points through week 48, the percentage of patients with VA ≥ 20/50 increased to 30%-40% at months 6 and 12 and remained stable through month 48. Spearman rank correlation demonstrated 2 independent variables that correlated with good visual outcome, smaller area of SFH at baseline (r = -0.630; P = .009), and high frequency of anti-VEGF injections (r = 0.646; P = .007). In exceptional patients with good visual outcome despite large baseline SFH, shortest distance between the fovea and hemorrhage border significantly correlated with baseline VA (r = -0.503, P = .047) and final VA (r = -0.575, P = .02). CONCLUSIONS: Patients with NVAMD and thick SFH, but short distance between fovea and uninvolved retina, can have good visual outcomes when given frequent anti-VEGF injections.

Optimizing the ULV-VFQ for Clinical Use Through Item Set Reduction: Psychometric Properties and Trade-Offs.

PURPOSE: We examine the dimensionality of the 150-item visual functioning questionnaire for individuals with ultralow vision (ULV-VFQ) and develop representative abbreviated versions, facilitating clinical use, while retaining compatibility with a 17-item performance assessment. METHODS: Subsets with 50 and 23 items covering the full difficulty range were selected, with evenly spaced item measures (IMs) and good representation of visual aspects and functional domains. Person measures (PMs) for the anchored subsets were derived through Rasch analysis of data from 80 respondents. RESULTS: Fit statistics for the reduced item sets were similar to those for the full set, with reliabilities at or above 95%. Mean PMs in the reduced sets were within 0.8 standard errors (SEs) of those in the full set. SEs of the PMs increased from the SE for 150 items, roughly in inverse proportion with the square root of the set size. Unexplained variance levels (24%-27%) and variance of the first unexplained factor (3.3%-3.9%) were close to those (30% and 2.6%) for 150 items. Differential item functions for omitted items were negligible. Aspects and domains are adequately represented in the reduced sets. CONCLUSIONS: Self-reported visual ability can be measured accurately using appropriately chosen anchored subsets of the ULV-VFQ. Functional ability of individuals with ULV is characterized adequately by a single dimension. TRANSLATIONAL RELEVANCE: The ULV-VFQ50 and ULV-VFQ23, using anchored IMs from the 150-item ULV-VFQ, provide an efficient and reliable self-report assessment of visual ability in individuals whose visual impairment is too severe for assessment with VFQs currently in use.

Development of the Ultra-Low Vision Visual Functioning Questionnaire (ULV-VFQ).

PURPOSE: To develop and psychometrically evaluate a visual functioning questionnaire (VFQ) in an ultra-low vision (ULV) population. METHODS: Questionnaire items, based on visual activities self-reported by a ULV population, were categorized by functional visual domain (e.g., mobility) and visual aspect (e.g., contrast) to ensure a representative distribution. In Round 1, an initial set of 149 items was generated and administered to 90 participants with ULV (visual acuity [VA] ≤ 20/500; mean [SD] age 61 [15] years), including six patients with a retinal implant. Psychometric properties were evaluated through Rasch analysis and a revised set (150 items) was administered to 80 participants in Round 2. RESULTS: In Round 1, the person measure distribution (range, 8.6 logits) was centered at -1.50 logits relative to the item measures. In Round 2, the person measure distribution (range, 9.5 logits) was centered at -0.86 relative to the item mean. The reliability index in both rounds was 0.97 for Items and 0.99 for Persons. Infit analysis showed four underfit items in Round 1, five underfit items in Round 2 with a z-score greater than 4 cutoff. Principal component analysis on the residuals found 69.9% explained variance; the largest component in the unexplained variance was less than 3%. CONCLUSIONS: The ULV-VFQ, developed with content generated from a ULV population, showed excellent psychometric properties as well as superior measurement validity in a ULV population. TRANSLATIONAL RELEVANCE: The ULV-VFQ, part of the Prosthetic Low Vision Rehabilitation (PLoVR) development program, is a new VFQ developed for assessment of functional vision in ULV populations.

Living with Ultra-Low Vision: An Inventory of Self-Reported Visually Guided Activities by Individuals with Profound Visual Impairment.

PURPOSE: To understand how individuals with profound visual impairment (ultra-low vision, ULV) use their remaining vision. METHODS: Forty-six participants with ULV (visual acuity ≤ 200/500 in the better seeing eye) were divided into nine focus groups (4-6 individuals per group) and met either in person (n = 2) or over the phone (n = 7). Discussions were guided by the Massof Activity Inventory. Audio recordings were transcribed and analyzed for visual activities that were then classified along two visual categorizations - functional domains and visual aspects. The latter was based on a Grounded Theory classification of participants' descriptions. RESULTS: Seven hundred sixty activities were reported. By functional domain they were classified as reading/shape recognition (10%), mobility (17%), visual motor (24%), and visual information gathering (49%). By visual aspects, they were classified as contrast (43%), luminance (17%), environmental lighting (9%), familiarity (3%), motion perception (5%), distance (7%), size (9%), eccentricity (5%), depth perception (1%), and other/miscellaneous (1%). More than one visual aspect may be critical for an activity: participants reported that contrast plays a role in 68% of visual activities, followed by luminance (27%), environmental lighting (14%), and size (14%). CONCLUSIONS: Visual aspects, primarily contrast, were found to be critical factors enabling ULV individuals to perform visual activities. TRANSLATIONAL RELEVANCE: This inventory, part of the Prosthetic Low Vision Rehabilitation (PLoVR) curriculum development study, provides a unique perspective into the visual world of the nearly blind, and can be used in the development of a Visual Functioning Questionnaire (VFQ) and visual performance measures suited for ULV populations.

Regression of choroidal neovascularization results in macular atrophy in anti-vascular endothelial growth factor-treated eyes.

PURPOSE: To determine the incidence and progression of macular atrophy in patients with neovascular age-related macular degeneration (AMD) treated with vascular endothelial growth factor (VEGF) antagonists. DESIGN: Retrospective interventional case series. METHODS: All patients with neovascular AMD treated by the same physician during a 12-month period of ascertainment had all images from their entire follow-up period evaluated, and areas of retina that developed atrophy were compared to the same areas prior to the onset of anti-VEGF treatment. Longitudinal measurements of retinal atrophy were made. RESULTS: In 39 patients, 52 eyes with neovascular AMD were identified. We excluded 5 eyes from analysis (4 had retinal pigment epithelium tears, and 1 had a laser scar). Fundus photographs of the remaining eyes showed that 18/47 eyes (38%) contained hypopigmented areas suggestive of atrophy within the macula at some time during follow-up. Spectral-domain optical coherence tomography confirmed that these areas had loss of retinal pigmented epithelium and ellipsoids zones, with or without subretinal material suggestive of subretinal fibrosis. Comparison of fundus photographs with fluorescein angiograms showed that in 13/18 eyes (72%), atrophy developed in areas previously occupied by choroidal neovascularization, and the other 5 eyes had atrophy prior to the onset of anti-VEGF treatment. The mean (± standard deviation) rate of increase in pure atrophic areas (no subretinal material) was 0.7 ± 0.8 mm(2) per year, with a range of 0.01-2.6 mm(2)/year. CONCLUSION: Treatment of neovascular AMD with a VEGF-neutralizing protein can result in regression of choroidal neovascularization, which is sometimes associated with atrophy of overlying retina.