Diagnostic accuracy of community optometrists for age-related macular degeneration using colour fundus photographs: A pilot evaluation.

PURPOSE: The accurate diagnosis of age-related macular degeneration (AMD) represents an important step in delaying and preventing vision loss and achieving optimal patient care. Therefore, this pilot study aimed to estimate the diagnostic accuracy of community optometrists for identifying AMD using colour fundus photographs (CFPs) to support sample size calculations for subsequent definitive studies. METHODS: Five practising community optometrists were invited to classify a total of 1023 CFPs for the (1) presence of AMD, and, if applicable, (2) stage of AMD (early/intermediate/late geographic atrophy/late neovascular AMD). Diagnosis by referral centre clinicians formed the reference standard. Diagnostic accuracy was assessed by the area under the receiver operating characteristic curve (aROC). Sensitivity, specificity, positive and negative predictive values were also calculated. RESULTS: Of the 1023 CFPs included in the study, 226 images were of AMD and 797 images were of other ocular conditions or no abnormal findings. Participating community optometrists had a mean (SD) age of 30.2 (8.9) years, 60.0% (3/5) were female and the mean number of years practising in primary eye care was 5.4 (5.4) years. Community optometrists demonstrated excellent performance for diagnosing AMD, with an aROC of 0.86 (95% CI 0.83 to 0.89), sensitivity of 84.5% (95% CI 79.1 to 89.0) and specificity of 88.0% (95% CI 85.5 to 90.1). The aROC (95% CI) for diagnosing early, intermediate, late geographic atrophy and late neovascular AMD was 0.82 (0.73 to 0.91), 0.76 (0.72 to 0.81), 0.69 (0.49 to 0.90) and 0.55 (0.34 to 0.75), respectively. CONCLUSIONS: These results justify the need for an appropriately powered definitive study to assess community clinicians' diagnostic accuracy for AMD.

Linking physiology and demographics, non-ocular pathology and pharmaceutical drug use to standard OCT measures of the inner retina: The PPP project.

PURPOSE: To assess the associations between physiology and demographics, non-ocular pathology and pharmaceutical drug use against peri-papillary retinal nerve fibre layer thickness (pRNFL T) and other optical coherence tomography (OCT) inner retinal measures in normal, healthy eyes. METHODS: A retrospective, cross-sectional study of 705 consecutive participants with bilateral normal, healthy optic nerves and maculae. PRNFL Ts, vertical cup/disc ratio (CDR), cup volume and macular ganglion cell layer-inner plexiform layer (GCL-IPL) Ts were extracted from Cirrus OCT scans, then regressed against predictor variables of participants' physiology and demographics (eye laterality, refraction, intraocular pressure [IOP], age, sex, race/ethnicity, etc.) and non-ocular pathology and pharmaceutical drug use according to the World Health Organisation classifications. Associations were assessed for statistical significance (p < 0.05) and clinical significance (|ß| > 95% limits of agreement for repeated measures). RESULTS: A multitude of non-ocular pathology and pharmaceutical drug use were statistically and clinically significantly associated with deviations in standard OCT inner retinal measures, exceeding the magnitude of other factors such as age, IOP and race/ethnicity. Thinner inner retina and larger optic nerve cup measures were linked to use of systemic corticosteroids, sex hormones/modulators, presence of vasomotor/allergic rhinitis and other diseases and drugs (up to -29.3 [-49.88, -8.72] µm pRNFL T, 0.31 [0.07, 0.54] vertical CDR, 0.29 [0.03, 0.54] mm3 cup volume and -10.18 [-16.62, -3.74] µm macular GCL-IPL T; all p < 0.05). Thicker inner retina and smaller optic nerve cup measures were diffusely associated with use of antineoplastic agents, presence of liver or urinary diseases and other diseases and drugs (up to 67.12 [64.92, 69.31] µm pRNFL T, -0.31 [-0.53, -0.09] vertical CDR, -0.06 [-0.11, 0] mm3 cup volume and 28.84 [14.51, 43.17] µm macular GCL-IPL T; all p < 0.05). CONCLUSION: There are a multitude of systemic diseases and drugs associated with altered OCT inner retinal measures, with magnitudes far exceeding those of other factors such as age, IOP and race/ethnicity. These systemic factors should at least be considered during OCT assessments to ensure precise interpretation of normal versus pathological inner retinal health.

Effective health communication for age-related macular degeneration: An exploratory qualitative study.

PURPOSE: Age-related macular degeneration (AMD) is a major cause of vision loss globally. Patients with AMD may not always understand or retain the information about AMD communicated by their eyecare practitioner. This study aims to explore the characteristics of effective health communication for AMD, from both patients' and eyecare practitioners' perspectives. The purpose is to provide a foundation for understanding how health communication for AMD could potentially be improved in the future. METHODS: A total of 10 focus groups involving 17 patients with AMD and 17 optometrists were conducted via web conferencing. Each session was audio-recorded, transcribed and analysed using the Grounded Theory Methodology. RESULTS: The five themes identified are as follows: (1) materials' quality, (2) materials' relevance, (3) contextualising for the individual, (4) contextualising for the disease and (5) support network. Participants expressed concern about the unrealistic yet common depiction of vision loss in AMD as a black patch overlying common visual scenes. They also preferred education materials tailored to a specific disease stage and the regular opportunity to ask or answer questions. Longer appointment durations and peer support (from family, friends or others with AMD) were also valued. CONCLUSION: Optometrists are encouraged to focus on three over-arching dimensions when counselling patients with AMD in routine clinical practice: (1) curating and using disease and stage-specific, impactful education materials, (2) their chairside verbal communication techniques and (3) AMD-specific opportunities for care coordination among patient family and friends, peers and other multidisciplinary members of the care support team.

Optometrists' attitudes toward using OCT angiography lag behind other retinal imaging types.

PURPOSE: While optometrists' attitudes toward established retinal imaging types are generally positive, they are unknown for optical coherence tomography angiography (OCTA). We performed a cross-sectional survey to estimate attitudes toward OCTA and identify clinician and/or practice characteristics that influence them. METHODS: A paper-based survey was mailed to 252 randomly selected optometrists in Australia. Five-point Likert-scale items from a previous survey assessing attitudes toward new technology were included to probe respondent characteristics and attitudes toward retinal imaging. Performance expectancy attitudes toward OCTA were elicited by the statement 'I believe OCTA is useful in daily practice'. Mean scores out of five (mean [SD]) were rounded and mapped to appropriate descriptive statements. RESULTS: The response rate was 47% (118/252). The mean (SD) age of respondents was 44.0 (13.8) years and 50.8% (60/118) were female. Optometrists had 19.9 (14.0) years of clinical experience and 66.9% (79/118) worked at independent practices. In total, 8.5% (10/118) of respondents used OCTA to provide clinical care. Optometrists agreed that optical coherence tomography (OCT), colour fundus imaging, ultra-wide field imaging and fundus autofluorescence (mean scores 3.6-4.7 out of 5) were useful in daily practice but felt neutral about whether OCTA was useful (3.4 [0.8]). Optometrists believed that OCTA was less enjoyable to use (p < 0.0001), less endorsed by peers (p < 0.0001) and felt less confident that they had the knowledge to interpret OCTA (p < 0.0001) compared to other retinal imaging types. CONCLUSIONS: Optometrists are undecided on whether OCTA is useful in daily practice and had lower expectations that using OCTA would confer job performance benefits compared to other retinal imaging types. Further work is needed to advocate the benefits of using OCTA across the profession.

Drusen-aware model for age-related macular degeneration recognition.

INTRODUCTION: The purpose of this study was to build an automated age-related macular degeneration (AMD) colour fundus photography (CFP) recognition method that incorporates confounders (other ocular diseases) and normal age-related changes by using drusen masks for spatial feature supervision. METHODS: A range of clinical sources were used to acquire 7588 CFPs. Contrast limited adaptive histogram equalisation was used for pre-processing. ResNet50 was used as the backbone network, and a spatial attention block was added to integrate prior knowledge of drusen features into the backbone. The evaluation metrics used were sensitivity, specificity and F1 score, which is the harmonic mean of precision and recall (sensitivity) and area under the receiver-operating characteristic (AUC). Fivefold cross-validation was performed, and the results compared with four other methods. RESULTS: Excellent discrimination results were obtained with the algorithm. On the public dataset (n = 6565), the proposed method achieved a mean (SD) sensitivity of 0.54 (0.09), specificity of 0.99 (0.00), F1 score of 0.62 (0.06) and AUC of 0.92 (0.02). On the private dataset (n = 1023), the proposed method achieved a sensitivity of 0.92 (0.02), specificity of 0.98 (0.01), F1 score of 0.92 (0.01) and AUC of 0.98 (0.01). CONCLUSION: The proposed drusen-aware model outperformed baseline and other vessel feature-based methods in F1 and AUC on the AMD/normal CFP classification task and achieved comparable results on datasets that included other diseases that often confound classification. The method also improved results when a five-category grading protocol was used, thereby reflecting discriminative ability of the algorithm within a real-life clinical setting.

Attitudes of optometrists towards artificial intelligence for the diagnosis of retinal disease: A cross-sectional mail-out survey.

PURPOSE: Artificial intelligence (AI)-based systems have demonstrated great potential in improving the diagnostic accuracy of retinal disease but are yet to achieve widespread acceptance in routine clinical practice. Clinician attitudes are known to influence implementation. Therefore, this study aimed to identify optometrists' attitudes towards the use of AI to assist in diagnosing retinal disease. METHODS: A paper-based survey was designed to assess general attitudes towards AI in diagnosing retinal disease and motivators/barriers for future use. Two clinical scenarios for using AI were evaluated: (1) at the point of care to obtain a diagnostic recommendation, versus (2) after the consultation to provide a second opinion. Relationships between participant characteristics and attitudes towards AI were explored. The survey was mailed to 252 randomly selected practising optometrists across Australia, with repeat mail-outs to non-respondents. RESULTS: The response rate was 53% (133/252). Respondents' mean (SD) age was 42.7 (13.3) years, and 44.4% (59/133) identified as female, whilst 1.5% (2/133) identified as gender diverse. The mean number of years practising in primary eye care was 18.8 (13.2) years with 64.7% (86/133) working in an independently owned practice. On average, responding optometrists reported positive attitudes (mean score 4.0 out of 5, SD 0.8) towards using AI as a tool to aid the diagnosis of retinal disease, and would be more likely to use AI if it is proven to increase patient access to healthcare (mean score 4.4 out of 5, SD 0.6). Furthermore, optometrists expressed a statistically significant preference for using AI after the consultation to provide a second opinion rather than during the consultation, at the point-of-care (+0.12, p = 0.01). CONCLUSIONS: Optometrists have positive attitudes towards the future use of AI as an aid to diagnose retinal disease. Understanding clinician attitudes and preferences for using AI may help maximise its clinical potential and ensure its successful translation into practice.

Assessment of patient education materials for age-related macular degeneration.

PURPOSE: Age-related macular degeneration (AMD) is a leading cause of vision loss. It is helpful for patients living with AMD to understand the prognosis, risk factors and management of their condition. Online education materials are a popular and promising channel for conveying this knowledge to patients with AMD. However, the quality of these materials-particularly with respect to qualities such as 'understandability' and 'actionability'-is not yet known. This study assessed a collection of online materials about AMD based on these qualities of 'understandability' and 'actionability'. METHODS: Online education materials about AMD were sourced through Google from six English-speaking nations: Australia, New Zealand, USA, UK, Ireland and Canada. Three Australian/New Zealand trained and registered optometrists participated in the grading of the 'understandability' and 'actionability' of online education materials using the Patient Education Materials Assessment Tool (PEMAT). RESULTS: This study analysed a total of 75 online materials. The mean 'understandability' score was 74% (range: 38%-94%). The 'understandability' PEMAT criterion U11 (calling for a summary of the key points) scored most poorly across all materials. The mean 'actionability' score was 49% (range: 0%-83%). The 'actionability' PEMAT criterion A26 (using 'visual aids' to make instructions easier to act on) scored most poorly across all materials. CONCLUSION: Most education materials about AMD are easy to understand, but difficult to act on, because of a lack of meaningful visual aids. We propose future enhancements to AMD education materials-including the use of summaries, visual aids and a habit tracker-to help patients with AMD improve their understanding of disease prognosis, risk factors and eye assessment schedule requirements.

Topical Review: Assessment of Binocular Sensory Processes in Low Vision.

SIGNIFICANCE: This article summarizes the evidence for a higher prevalence of binocular vision dysfunctions in individuals with vision impairment. Assessment for and identification of binocular vision dysfunctions can detect individuals experiencing difficulties in activities including reading, object placement tasks, and mobility.Comprehensive vision assessment in low vision populations is necessary to identify the extent of remaining vision and to enable directed rehabilitation efforts. In patients with vision impairment, little attention is typically paid to assessments of binocular vision, including ocular vergence, stereopsis, and binocular summation characteristics. In addition, binocular measurements of threshold automated visual fields are not routinely performed in clinical practice, leading to an incomplete understanding of individuals' binocular visual field and may affect rehabilitation outcomes.First, this review summarizes the prevalence of dysfunctions in ocular vergence, stereopsis, and binocular summation characteristics across a variety of ocular pathologies causing vision impairment. Second, this review examines the links between clinical measurements of binocular visual functions and outcome measures including quality of life and performance in functional tasks. There is an increased prevalence of dysfunctions in ocular alignment, stereopsis, and binocular summation across low vision cohorts compared with those with normal vision. The identification of binocular vision dysfunctions during routine low vision assessments is especially important in patients experiencing difficulties in activities of daily living, including but not limited to reading, object placement tasks, and mobility. However, further research is required to determine whether addressing the identified deficits in binocular vision in low vision rehabilitative efforts directly impacts patient outcomes.

Retinal Nerve Fiber Layer Protrusion Associated with Tilted Optic Discs.

SIGNIFICANCE: This study resulted in the identification of an optic nerve head (ONH) feature associated with tilted optic discs, which might potentially contribute to ONH pathologies. Knowledge of such findings will enhance clinical insights and drive future opportunities to understand disease processes related to tilted optic discs. PURPOSE: The aim of this study was to identify novel retinal nerve fiber layer (RNFL) anomalies by evaluating tilted optic discs using optical coherence tomography. An observed retinal nerve fiber protrusion was further investigated for association with other morphological or functional parameters. METHODS: A retrospective review of 400 randomly selected adult patients with ONH examinations was conducted in a referral-only, diagnostic imaging center. After excluding other ONH pathologies, 215 patients were enrolled and evaluated for optic disc tilt and/or torsion. Gross anatomical ONH features, including size and rim or parapapillary region elevation, were assessed with stereoscopic fundus photography. Optical coherence tomography provided detailed morphological information of individual retinal layers. Statistical analysis was applied to identify significant changes between individual patient cohorts. RESULTS: A dome-shaped hyperreflective RNFL bulge, protruding into the neurosensory retina at the optic disc margins, was identified in 17 eyes with tilted optic discs. Available follow-up data were inconclusive regarding natural changes with this ONH feature. This RNFL herniation was significantly correlated with smaller than average optic disc size (P = .005), congenital disc tilt (P < .0001), and areas of rim or parapapillary elevation (P < .0001). CONCLUSIONS: This study reports an RNFL protrusion associated with tilted optic discs, which has not previously been assessed as an independent ONH structure. The feature is predominantly related to congenital crowded, small optic discs and variable between patients. This study is an important first step to elucidate diagnostic capabilities of tilted disc morphological changes and understanding associated functional deficits.

Peripheral retinal findings in populations with macular disease are similar to healthy eyes.

PURPOSE: Recent evidence suggests several macular diseases are associated with peripheral retinal changes. This study investigated the number, type and management consequences of peripheral retinal findings detected in patients attending a referral only, eye-care clinic, the Centre for Eye Health(CFEH) with macular disease. METHODS: Records of 537 patients attending CFEH for a macular assessment were included in the study. Subjects were classified as having age-related macular degeneration (AMD), epiretinal membrane (ERM), central serous chorioretinopathy (CSCR), inherited macular dystrophy or no macular disease. Data extracted included reason for referral, macular findings, peripheral findings (based on examination by ultra-widefield scanning laser ophthalmoscopy), diagnosis and management. RESULTS: After age-matching, the number of peripheral findings in subjects with AMD, ERM or CSCR was not significant different to normal subjects. The most common finding for all cohorts were non-specific, degenerative changes such as drusen or pigmentation (61-72%) except inherited macular dystrophy subjects who had mostly vascular findings (30%; p < 0.05). Subjects with AMD and ERM with peripheral findings were significantly more likely to be reviewed or referred to an ophthalmologist than discharged back to their community eye care provider compared to subjects without findings. However only 8% of subjects had altered management based specifically on peripheral findings suggesting the macular findings in most subjects dictated their management. For those with a change, it was significant (upgrade to referral to an ophthalmologist). Peripheral findings also flagged 5% of subjects with vascular findings for referral to their general practitioner (GP). CONCLUSIONS: Overall, the percentage and distribution of peripheral retinal findings in some macular diseases was similar to normal subjects. However, subjects with peripheral findings appeared to have significant differences in management. Considering some common findings, such as peripheral drusen may be relevant to AMD pathogenesis and therefore affect management of this disease, assessment of the peripheral retina should not be overlooked when the clinical focus is on the posterior pole.

Fundus Autofluorescence in Age-related Macular Degeneration.

: Fundus autofluorescence (FAF) provides detailed insight into the health of the retinal pigment epithelium (RPE). This is highly valuable in age-related macular degeneration (AMD) as RPE damage is a hallmark of the disease. The purpose of this paper is to critically appraise current clinical descriptions regarding the appearance of AMD using FAF and to integrate these findings into a chair-side reference. A wide variety of FAF patterns have been described in AMD, which is consistent with the clinical heterogeneity of the disease. In particular, FAF imaging in early to intermediate AMD has the capacity to reveal RPE alterations in areas that appear normal on funduscopy, which aids in the stratification of cases and may have visually significant prognostic implications. It can assist in differential diagnoses and also represents a reliable, sensitive method for distinguishing reticular pseudodrusen. FAF is especially valuable in the detection, evaluation, and monitoring of geographic atrophy and has been used as an endpoint in clinical trials. In neovascular AMD, FAF reveals distinct patterns of classic choroidal neovascularization noninvasively and may be especially useful for determining which eyes are likely to benefit from therapeutic intervention. FAF represents a rapid, effective, noninvasive imaging method that has been underutilized, and incorporation into the routine assessment of AMD cases should be considered. However, the practicing clinician should also be aware of the limitations of the modality, such as in the detection of foveal involvement and in the distinction of phenotypes (hypo-autofluorescent drusen from small areas of geographic atrophy).

The advantages of intermediate-tier, inter-optometric referral of low risk pigmented lesions.

PURPOSE: Pigmented ocular lesions are commonly encountered by eye-care professionals, and range from benign to sight or life-threatening. After identifying a lesion, the primary care professional must establish the likely diagnosis and decide either to reassure, to monitor or to refer. The increasing use of ocular imaging technologies has contributed to an increase in the detection rate of pigmented lesions and a higher number of referrals, which may challenge existing pathways of health-care delivery. Specialist services may be over-burdened by referring all patients with pigmented lesions for an opinion, while inter-optometric referrals are underutilised. The aim of this study was to describe the referral patterns of pigmented lesions to an optometry led intermediate-tier collaborative care clinic. METHODS: We performed a retrospective review of patient records using the list of patients examined at Centre for Eye Health (CFEH) for an initial or follow up pigmented lesion assessment between the 1/7/2013 and the 30/6/2016. Analysis was performed on: patient demographic characteristics, the referrer's tentative diagnosis, CFEH diagnosis and recommended management plan. RESULTS: Across 182 patient records, the primary lesion prompting referral was usually located in the posterior segment: choroidal naevus (105/182, 58%), congenital hypertrophy of the retinal pigment epithelium (CHRPE; 11/182, 6%), chorioretinal scarring (10/182, 5%) or not specified (52/182, 29%). Referrals described a specific request for ocular imaging in 25 instances (14%). The number of cases with a non-specific diagnosis was reduced after intermediate-tier care assessment (from 29% to 10%), while the number of diagnoses with less common conditions rose (from 2% to 21%). There was a 2% false positive referral rate to intermediate-tier care and a first visit discharge rate of 35%. A minority required on-referral to an ophthalmologist (22/182, 12%), either for unrelated incidental ocular findings, or suspicious choroidal naevi. Conditions most amenable to optometric follow up included: 1) chorioretinal scarring, 2) choroidal naevus, and 3) CHRPE. CONCLUSIONS: Intermediate-tier optometric eye-care in pigmented lesions (following opportunistic primary care screening) has the potential to reduce the number of cases with non-specific diagnoses and to increase those with less common diagnoses. The majority of cases seen under this intermediate-tier model required only ongoing optometric surveillance.

Collaborative care of non-urgent macular disease: a study of inter-optometric referrals.

PURPOSE: Diseases involving the macula and posterior pole are leading causes of visual impairment and blindness worldwide and may require prompt ophthalmological care. However, access to eye-care and timely patient management may be limited due to inefficient and inappropriate referrals between primary eye-care providers and ophthalmology. Optometrists with a special interest in macular disease may be useful as a community aid to better stratify and recommend best-practice management plans for suitable patients. This study assesses such a notion by appraising the optometric referral patterns of patients with suspected macular disease to an intermediate-tier optometric imaging clinic. METHODS: We performed a retrospective review of patient records and referrals using patients examined at Centre for Eye Health (CFEH) for an initial or follow up macular assessment between the 1/7/2013 and 30/6/2014 (n = 291). The following data were analysed: patient demographic characteristics, primary reason for referral, diagnosed/suspected condition, CFEH diagnosis and recommended management plan. RESULTS: The number of referrals stipulating a diagnosis, confirmed after evaluation at CFEH was 121 of 291 (42%). After evaluation at CFEH, the number of cases without a specific diagnosis was approximately halved (reduced from 47% to 23%), while the number of cases with no apparent defect or normal aging changes rose from 1% to 15%. Overall diagnostic congruency for specified macular conditions was high (58-94%); cases were seldom (30/291, 10%) found to have a completely different macular condition. 244 of 291 (84%) patients seen at CFEH were recommended ongoing optometric care: either with the referring optometrist or through recall to CFEH. Referral to an ophthalmologist was recommended in 47 instances (16%). CONCLUSIONS: More widespread adoption of intermediate-tier optometric eye-care referral pathways in macular disease (following opportunistic primary care screening) has the potential to reduce the number of cases with non-specific diagnoses and to increase those with a diagnosis of normal aging changes or no apparent disease. The majority of cases seen under this intermediate-tier model required ongoing optometric care only and did not require face-to-face consultation with an ophthalmologist.

Infrared reflectance imaging in age-related macular degeneration.

PURPOSE: The purpose of this article is to describe the appearance of age-related macular degeneration (AMD) phenotypes using infrared (IR) reflectance imaging. IR reflectance imaging of the retina has the potential to highlight specific sub-retinal features and pathology. However, its role in macular disease, specifically AMD, is often underestimated and requires clarification. RECENT FINDINGS: Recent advances in clinical methods, imaging and scientific knowledge may be integrated to improve the accuracy of disease stratification in AMD. In particular, IR imaging holds an underutilised sensitivity to detect reticular pseudodrusen, which have been repeatedly described as a high-risk sign for late AMD. SUMMARY: This article provides clinically relevant descriptions of AMD phenotypes using IR reflectance imaging. The findings are integrated with images from cases seen at the Centre for Eye Health. As primary eye-care providers assume a critical role in the detection, diagnosis and management of AMD, we also provide a chair-side reference to assist clinicians in interpreting IR images in AMD.

Pigmented Lesions of the Retinal Pigment Epithelium.

: The primary eye care practitioner assumes an important role in clinical decisions involving the differentiation between malignant and nonmalignant pigmented lesions. A misdiagnosis may have profound consequences on patient management and visual or life prognosis. However, information on these lesions, particularly their appearance using advanced imaging, is fragmented throughout the literature. The purpose of this review is to describe these features in detail, so that the implications of this information on clinical practice are more readily apparent. Clinically relevant descriptions of pigmented lesions of the retinal pigment epithelium using traditional and advanced imaging modalities in the literature were collated and integrated with findings from patients seen at the Centre for Eye Health. The information was then organized and tabulated. Finally, a flow diagram was created to be used as a clinical reference in the differential diagnosis of pigmented lesions of the retinal pigment epithelium.

A survey of eyecare affordability among patients seen in collaborative care in Australia and factors contributing to cost barriers.

AIM: The decline in the real value of rebates from Australia's national public health insurance scheme, Medicare, over the past decade has contributed to increased out-of-pocket costs for eyecare services, which threatens affordability. This study measured eyecare affordability and cost barriers among patients seen in collaborative care. METHODS: We conducted a cross-sectional survey of 252 patients who had attended a collaborative eyecare clinic in the previous year. A modified affordability subscale was used to measure eyecare and general healthcare affordability. Two population scores were calculated: the average percentage of patients experiencing cost barriers (mean of the five item percentages for general healthcare, and optometric and specialist eyecare), and the proportion indicating one or more cost barriers. Factors associated with eyecare and general healthcare affordability were identified using linear regression. RESULTS: The response rate was 46.8% (n = 118/252). The mean percentage of patients not obtaining services because of cost ranged from 23.4% (standard deviation [SD] 8.8) for general healthcare to 25.5% (SD 6.3) for specialist eyecare. Direct or indirect cost barriers to one or more services were experienced by 45.2% (n = 52/115) of respondents for optometric eyecare and 40.4% (n = 44/109) for specialist eyecare. Services not covered by private health insurance or Medicare (for example, out-of-pocket dental and optical) were ranked the most difficult to afford. Poorer self-rated health (p = 0.004, ß = 0.293) and the lack of private hospital health insurance (p = 0.014, ß= 0.249) were associated with reduced optometric eyecare affordability. This was also true for specialist eyecare affordability (self-rated health p = 0.002, ß = 0.306; private hospital health insurance p = 0.004, ß = 0.286). A lack of private hospital health insurance (p = 0.001, ß = 0.312), younger age (p < 0.001, ß = -0.418) and holding a concession card (p = 0.011, ß = 0.272) were all associated with reduced affordability of general healthcare. CONCLUSION: A high proportion of patients seen in collaborative care experience cost barriers to accessing eyecare, particularly for services not covered by private health insurance or Medicare. These findings indicate that affordability concerns exist despite significant reductions in the direct cost of services within a collaborative care setting. They also provide insights on the subpopulations most vulnerable to rising eyecare costs.

OCT Prognostic Biomarkers for Progression to Late Age-related Macular Degeneration: A Systematic Review and Meta-analysis.

TOPIC: To evaluate which OCT prognostic biomarkers best predict the risk of progression from early/intermediate to late age-related macular degeneration (AMD). CLINICAL RELEVANCE: Among > 100 OCT prognostic biomarkers for AMD, it is unclear which are the most relevant for clinicians and researchers to focus on. This review evaluated which OCT biomarkers confer the greatest magnitude of prediction for progression to late AMD. METHODS: Study protocol was registered on PROSPERO (CRD42023400166). PubMed and Embase were searched from inception to March 2, 2023, and eligible studies assessed following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The primary outcome was any quantified risk of progression from treatment-naive early/intermediate AMD to late AMD, including hazard ratios (HRs), odds ratios (ORs), and standardized mean differences (at baseline, between eyes with versus without progression), subgrouped by each OCT biomarker. Further meta-analyses were subgrouped by progression to geographic atrophy or neovascularization. RESULTS: A total of 114 quantified OCT prognostic biomarkers were identified. With high GRADE certainty of evidence, the greatest magnitudes of prediction to late AMD belonged to: external limiting membrane abnormality (OR, 15.42 [7.63, 31.17]), ellipsoid zone abnormality (OR, 10.8 [4.58, 25.46]), interdigitation zone abnormality (OR, 7.68 [2.57, 23]), concurrent large drusen and reticular pseudodrusen (HR, 6.73 [1.35, 33.65], hyporeflective drusen cores (HR, 2.48 [1.8, 3.4]; OR 1.85 [1.29, 2.66]), intraretinal hyperreflective foci (IHRF; HR, 2.16 [0.92, 5.07]; OR 5.08 [3.26, 7.92]), and large drusen (HR, 2.01 [1.35, 2.99]); OR, 1.98 [1.27, 3.08]). There was greater risk of geographic atrophy for IHRF and hyporeflective drusen cores (P < 0.05), and neovascularization for ellipsoid zone abnormality (P < 0.05). Other OCT biomarkers such as drusenoid pigment epithelium detachment, shallow irregular retinal pigment epithelium elevations, and nascent geographic atrophy exhibited large magnitudes of risk but required further studies for validation. CONCLUSION: This review synthesizes the 6 most relevant OCT prognostic biomarkers for AMD with greater predictive ability than large drusen alone, for clinicians and researchers to focus on. Further study is required to validate other biomarkers with less than high certainty of evidence, and assess how the copresence of biomarkers may affect risks. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Diagnostic accuracy of OCTA and OCT for myopic choroidal neovascularisation: a systematic review and meta-analysis.

BACKGROUND/OBJECTIVES: The purpose of this project was to systematically review and meta-analyse studies assessing the diagnostic accuracy of optical coherence tomography angiography (OCTA) and optical coherence tomography (OCT) for myopic choroidal neovascularisation (mCNV). Fluorescein angiography (FA) was accepted as the reference standard. METHODS: PUBMED and EMBASE were searched from inception to March 2021 for studies evaluating the test accuracy of OCTA and/or OCT for diagnosing mCNV. The Preferred Reporting Items for Systematic Reviews and Meta-analyses of Diagnostic Test Accuracy Studies guideline was followed, and the Grading of Recommendations, Assessment, Development and Evaluation approach was used to frame clinical recommendations. Pooled estimates of test accuracy were obtained using a bivariate model. RESULTS: Of 410 studies assessed for eligibility, 3 studies were identified that compared OCTA to FA and 3 studies were identified that compared spectral domain (SD) OCT to FA. All studies had at least one major methodological flaw leading to an overall high risk of bias. On meta-analysis, the pooled sensitivity of OCTA was 0.89 (95% CI 0.78-0.94) and pooled specificity was 0.93 (95% CI 0.79-0.98). The pooled sensitivity of SD-OCT was 0.99 (95% CI 0.91-1.00). Due to uncertainty in individual studies, the pooled specificity of SD-OCT could not be estimated. CONCLUSIONS: OCTA can reliably diagnose mCNV in clinically suspected patients, however, SD-OCT may not reliably establish a positive diagnosis of mCNV. Future large, prospective studies with improvements in conduct and reporting are needed to strengthen these clinical recommendations.

Evaluating the clinical relevance and reliability of outer retinal band length on optical coherence tomography in retinal disease: a cross-sectional study.

OBJECTIVES: Hyper-reflective outer retinal band (HORB) disruptions are reported across a range of retinal disease, yet a reliable, easily implemented assessment method and thorough evaluation of their association to retinal disease is lacking. The purpose of the study was to assess the reliability of using magnitude estimation to evaluate HORB length and determine its association to visual acuity and retinal disease. DESIGN: Cross-sectional, retrospective study. SETTING: Patients attending a secondary eye care clinic in Sydney, Australia. PARTICIPANTS: 2039 unique consecutive patients were screened for inclusion between 2 November and 18 January 2021, and 600 were included in the study population. Patients were included if they were referred from primary care, presented for an initial, comprehensive eye examination during the study period, imaged with optical coherence tomography during their visit and over 18 years of age. PRIMARY OUTCOME: Reliability of HORB length estimations and associations to clinical outcomes. RESULTS: Intragrader (intraclass correlation coefficient, ICCfovea=0.81; ICCworst=0.91) and intergrader (ICCfovea=0.78-0.79; ICCworst=0.75-0.88) agreement of HORB length was good to excellent. HORB length was significantly associated with age (p<0.001, ß=-0.22 to -0.24) and refractive error (p<0.001, ß=0.12-0.16) at all B-scan locations. Visual acuity (p=0.001, ß=-0.13) was associated with the primary outcome for foveal B-scans and eccentricity (p=0.002, ß=-0.13) and device type (p=0.002, ß=0.13) for non-foveal B-scans. Glaucoma was associated with HORB length on univariate analysis (p=0.05-0.06, ß=-0.08); however, multivariate analysis revealed no significant association between HORB length and retinal disease. CONCLUSION: HORB length is reliably assessed using magnitude estimation and may be useful as a surrogate biomarker of visual acuity. Several factors affect HORB length estimations, which may contribute to the lack of association to retinal disease and highlights the need for covariable adjustment when examining HORB disruptions.

Clinical decision support in primary care for better diagnosis and management of retinal disease.

Misdiagnosis of retinal disease is a common problem in primary care that can lead to irreversible vision loss and false-positive referrals, resulting in inappropriate use of health services. Clinical decision support systems describe tools that leverage information technology to provide timely recommendations that assist clinicians in the decisions they make about the care of a patient. They, therefore, have the potential to reduce the rate of misdiagnosis by promoting evidence-based medicine and more effective and efficient healthcare. This narrative review aims to support primary care practitioners in better understanding the current and emerging capacity of clinical decision support systems in eye care. Different types of clinical decision support systems are discussed, using current examples and evidence from the available literature to demonstrate how they may improve diagnostic effectiveness and aid the management of retinal disease. Comments are made on the future directions of clinical decision support in primary eye care and the potential applications of artificial intelligence.