Descriptive study of the challenges when implementing an app for patients with neovascular age-related macular degeneration to monitor their vision at home.

OBJECTIVES: Remote monitoring of health has the potential to reduce the burden to patients of face-to-face appointments and make healthcare more efficient. Apps are available for patients to self-monitor vision at home, for example, to detect reactivation of age-related macular degeneration (AMD). Describing the challenges when implementing apps for self-monitoring of vision at home was an objective of the MONARCH study to evaluate two vision-monitoring apps on an iPod Touch (Multibit and MyVisionTrack). DESIGN: Diagnostic Test Accuracy study. SETTING: Six UK hospitals. METHODS: The study provides an example of the real-world implementation of such apps across health sectors in an older population. Challenges described include the following: (1) frequency and reason for incoming calls made to a helpline and outgoing calls made to participants; (2) frequency and duration of events responsible for the tests being unavailable; and (3) other technical and logistical challenges. RESULTS: Patients (n=297) in the study were familiar with technology; 252/296 (85%) had internet at home and 197/296 (67%) had used a smartphone. Nevertheless, 141 (46%) called the study helpline, more often than anticipated. Of 435 reasons for calling, all but 42 (10%) related to testing with the apps or hardware, which contributed to reduced adherence. The team made at least one call to 133 patients (44%) to investigate why data had not been transmitted. Multibit and MyVisionTrack apps were unavailable for 15 and 30 of 1318 testing days for reasons which were the responsibility of the app providers. Researchers also experienced technical challenges with a multiple device management system. Logistical challenges included regulations for transporting lithium-ion batteries and malfunctioning chargers. CONCLUSIONS: Implementation of similar technologies should incorporate a well-resourced helpline and build in additional training time for participants and troubleshooting time for staff. There should also be robust evidence that chosen technologies are fit for the intended purpose. TRIAL REGISTRATION NUMBER: ISRCTN79058224.

Home vision monitoring in patients with maculopathy: current and future options for digital technologies.

Patients with macular pathology, including that caused by age-related macular degeneration and diabetic macular oedema, must attend frequent in-clinic monitoring appointments to detect onset of disease activity requiring treatment and to monitor progression of existing disease. In-person clinical monitoring places a significant burden on patients, caregivers and healthcare systems and is limited in that it only provides clinicians with a snapshot of the patient's disease status. The advent of remote monitoring technologies offers the potential for patients to test their own retinal health at home in collaboration with clinicians, reducing the need for in-clinic appointments. In this review we discuss visual function tests, both existing and novel, that have the potential for remote use and consider their suitability for discriminating the presence of disease and progression of disease. We then review the clinical evidence supporting the use of mobile applications for monitoring of visual function from clinical development through to validation studies and real-world implementation. This review identified seven app-based visual function tests: four that have already received some form of regulatory clearance and three under development. The evidence included in this review shows that remote monitoring offers great potential for patients with macular pathology to monitor their condition from home, reducing the need for burdensome clinic visits and expanding clinicians' understanding of patients' retinal health beyond traditional clinical monitoring. In order to instil confidence in the use of remote monitoring in both patients and clinicians further longitudinal real-world studies are now warranted.

Eye tracking: empirical foundations for a minimal reporting guideline.

In this paper, we present a review of how the various aspects of any study using an eye tracker (such as the instrument, methodology, environment, participant, etc.) affect the quality of the recorded eye-tracking data and the obtained eye-movement and gaze measures. We take this review to represent the empirical foundation for reporting guidelines of any study involving an eye tracker. We compare this empirical foundation to five existing reporting guidelines and to a database of 207 published eye-tracking studies. We find that reporting guidelines vary substantially and do not match with actual reporting practices. We end by deriving a minimal, flexible reporting guideline based on empirical research (Section "An empirically based minimal reporting guideline").

Patient Acceptability of Home Monitoring for Neovascular Age-Related Macular Degeneration Reactivation: A Qualitative Study.

Neovascular age-related macular degeneration (nAMD) is a chronic, progressive condition and the commonest cause of visual disability in older adults. This study formed part of a diagnostic test accuracy study to quantify the ability of three index home monitoring (HM) tests (one paper-based and two digital tests) to identify reactivation in nAMD. The aim of this qualitative research was to investigate patients' or participants' views about acceptability and explore adherence to weekly HM. Semi-structured interviews were held with 78/297 participants (26%), with close family members (n = 11) and with healthcare professionals involved in training participants in HM procedures (n = 9) (n = 98 in total). A directed thematic analytical approach was applied to the data using a deductive and inductive coding framework informed by theories of technology acceptance. Five themes emerged related to: 1. The role of HM; 2. Suitability of procedures and instruments; 3. Experience of HM; 4. Feasibility of HM in usual practice; and 5. Impediments to patient acceptability of HM. Various factors influenced acceptability including a patient's understanding about the purpose of monitoring. While initial training and ongoing support were regarded as essential for overcoming unfamiliarity with use of digital technology, patients viewed HM as relatively straightforward and non-burdensome. There is a need for further research about how use of performance feedback, level of support and nature of tailoring might facilitate further the implementation of routinely conducted HM. Home monitoring was acceptable to patients and they recognised its potential to reduce clinic visits during non-active treatment phases. Findings have implications for implementation of digital HM in the care of older people with nAMD and other long-term conditions.

The COVID-19 Pandemic and Ophthalmic Care: A Qualitative Study of Patients with Neovascular Age-Related Macular Degeneration (nAMD).

Concerns have been expressed about the relationship between reduced levels of health care utilisation and the COVID-19 pandemic. This study aimed to elicit and explore the views of patients with neovascular age-related macular degeneration (nAMD) regarding the COVID-19 pandemic and their ophthalmic care. Semi-structured telephone interviews were conducted with thirty-five patients with nAMD taking part in a larger diagnostic accuracy study of home-monitoring tests. Participants were recruited using maximum variation sampling to capture a range of key characteristics including age, gender and time since initial treatment. Transcribed interview data were analysed using a deductive and inductive thematic approach. Three themes emerged from the analysis: i. access to eye clinic care. ii. COVID-19-mitigating factors and care delivery and iii. social and personal circumstances. Participants reported anxieties about cancelled or delayed appointments, limited communication from clinic-based services about appointments, and the impact of this on their ongoing care. Despite these concerns, there was apprehension about attending appointments due to infection risk and a perception that nAMD patients are a 'high risk' group. Views of those who attended clinics during the study period were, however, positive, with social distancing and infection control measures providing reassurance. These findings contribute to our understanding about experiences of patients with nAMD during the COVID-19 pandemic and may have potential implications for future planning of care services in similar circumstances. Innovative approaches may be required to address issues related to access to care, including concerns about delayed or cancelled appointments.

Confirmation of age-related alterations in inhibitory control using a modified minimally delayed oculomotor response (MDOR) task.

Considerable effort has been made to measure and understand the effects of ageing on inhibitory control using a range of behavioural tasks. In the minimally delayed oculomotor response (MDOR) task, participants are presented with a simple visual target step with variable target display duration (TDD), and instructed to saccade to the target not when it appears (a prosaccade response), but when it disappears (i.e., on target offset). Using this task, we recently found higher error rates and longer latencies for correct responses in older compared to younger participants. Here we have used a modified MDOR task, in which participants were presented with static placeholders identifying potential target positions (increasing spatial information), and three TDDs rather than two (reducing temporal predictability). We found that the yield of analysable trials was generally higher with this modified task and in 28 older (mean ± SD age: 65 ± 7 y) and 25 younger (26 ± 7 y) participants the total overall error rate was again higher in the older group (30 ± 18% vs. 16 ± 11%). An analysis of the temporal distribution of responses demonstrated a pronounced peak in error production around 150 ms (young) or 200 ms (old) after target onset. When we recalculated the error rate focusing on these errors, it was again significantly higher in the older group. The latency of correct responses (to offsets) was significantly increased in the older group, although much of this increase was accounted for by expected age-related visuomotor slowing. However, both latency and distribution data suggested that while older participants could generate increased levels of inhibition, they could not maintain these levels as efficiently as the younger participants. In 24 participants (15 old, 9 young) who completed both versions of the MDOR task, neither latency nor error rates differed significantly between versions. These results confirm an inhibitory control deficit in healthy older participants, and suggest that the dynamics of inhibitory control are also affected by ageing. The modified MDOR task yields more data while not altering basic performance parameters.

Monitoring for neovascular age-related macular degeneration (AMD) reactivation at home: the MONARCH study.

AIMS: This study aims to quantify the diagnostic test-accuracy of three visual function self-monitoring tests for detection of active disease in patients with neovascular age-related macular degeneration (nAMD) when compared with usual care. An integrated qualitative study will investigate the acceptability of these home-based testing strategies. METHODS: All consenting participants are provided with an equipment pack containing an iPod touch with two vision test applications installed and a paper journal of reading tests. Participants self-monitor their vision at home each week with all three tests for 12-18 months. Usual care continues over this period. Key eligibility criteria are: age ≥50 years; at least one eye with AMD with ≥6-≤42 months since first AMD treatment; and vision not worse than Snellen 6/60, LogMAR 1.04 or 33 letters. The primary outcome, and reference standard, is diagnosis of active disease during usual care monitoring in the Hospital Eye Service. Secondary outcomes include duration of study participation, ability of participants to do the tests, adherence to weekly testing and acceptability of the tests to participants. CONCLUSIONS: Recruitment is in progress at five NHS centres. Challenges in procuring equipment, setting up the devices and transporting devices containing lithium batteries to participating sites delayed the start of recruitment. The study will describe the performance of the tests self-administered at home in detecting active disease compared to usual care monitoring. It will also describe the feasibility of the NHS implementing patient-administered electronic tests or similar applications at home for monitoring health.

Age-related alterations in inhibitory control investigated using the minimally delayed oculomotor response task.

Healthy, older adults are widely reported to experience cognitive decline, including impairments in inhibitory control. However, this general proposition has recently come under scrutiny because ageing effects are highly variable between individuals, are task dependent, and are sometimes not distinguished from general age-related slowing. We recently developed the minimally delayed oculomotor response (MDOR) task in which participants are presented with a simple visual target step, and instructed to saccade not to the target when it appears (a prosaccade response), but when it disappears (i.e. on target offset). Varying the target display duration (TDD) prevents offset timing being predictable from the time of target onset, and saccades prior to the offset are counted as errors. A comparison of MDOR task performance in a group of 22 older adults (mean age 62 years, range 50-72 years) with that in a group of 39 younger adults (22 years, range 19-27 years) demonstrated that MDOR latency was significantly increased in the older group by 34-68 ms depending on TDD. However, when MDOR latencies were corrected by subtracting the latency observed in a standard prosaccade task, the latency difference between groups was abolished. There was a larger latency modulation with TDD in the older group which was observed even when their generally longer latencies were taken into account. Error rates were significantly increased in the older group. An analysis of the timing distribution of errors demonstrated that most errors were failures to inhibit responses to target onsets. When error distributions were used to isolate clear inhibition failures from other types of error, the older group still exhibited significantly higher error rates as well as a higher residual error rate. Although MDOR latency in older participants may largely reflect a general slowing in the oculomotor system with age, both the latency modulation and error rate results are consistent with an age-related inhibitory control deficit. How this relates to performance on other inhibitory control tasks remains to be investigated.

Spatial Linear Mixed Effects Modelling for OCT Images: SLME Model.

Much recent research focuses on how to make disease detection more accurate as well as "slimmer", i.e., allowing analysis with smaller datasets. Explanatory models are a hot research topic because they explain how the data are generated. We propose a spatial explanatory modelling approach that combines Optical Coherence Tomography (OCT) retinal imaging data with clinical information. Our model consists of a spatial linear mixed effects inference framework, which innovatively models the spatial topography of key information via mixed effects and spatial error structures, thus effectively modelling the shape of the thickness map. We show that our spatial linear mixed effects (SLME) model outperforms traditional analysis-of-variance approaches in the analysis of Heidelberg OCT retinal thickness data from a prospective observational study, involving 300 participants with diabetes and 50 age-matched controls. Our SLME model has a higher power for detecting the difference between disease groups, and it shows where the shape of retinal thickness profiles differs between the eyes of participants with diabetes and the eyes of healthy controls. In simulated data, the SLME model demonstrates how incorporating spatial correlations can increase the accuracy of the statistical inferences. This model is crucial in the understanding of the progression of retinal thickness changes in diabetic maculopathy to aid clinicians for early planning of effective treatment. It can be extended to disease monitoring and prognosis in other diseases and with other imaging technologies.

Radial shape discrimination testing for new-onset neovascular age-related macular degeneration in at-risk eyes.

We investigated the performance of the handheld radial shape discrimination (hRSD) test in detecting the development of neovascular AMD (nAMD) in a prospective, longitudinal, observational study. Patients diagnosed with unilateral nAMD, with no nAMD in the other eye (the study eye, SE), completed the hRSD test on consecutive, routine clinic visits up to a maximum of 12, or until they were diagnosed with nAMD in the SE based on slit-lamp biomicroscopy and spectral-domain OCT assessment, with fluorescein angiography confirmation. Masked grading was carried out to confirm the diagnosis of nAMD, and to ensure no cases of nAMD were missed. Receiver operating characteristics (ROC) analysis was used to explore the diagnostic performance of the hRSD test relative to clinical diagnosis. Data were available from 179 patients of whom 19 (10.6%; "converters") developed nAMD in the SE. The mean hRSD threshold at conversion was -0.47 (95% CI -0.38 to -0.55) logMAR compared to -0.53 (-0.50 to -0.57) logMAR in 160 non-converters. hRSD threshold in the converters began to decline 190 days before diagnosis of nAMD. The ROC curve demonstrated that at an hRSD cut-off of -0.60 logMAR, sensitivity was 0.79 (0.54-0.94) with a specificity of 0.54 (0.46-0.62); positive and negative predictive values were 0.16 and 0.96 respectively. We conclude that the hRSD test has moderate sensitivity for detecting the earliest stages of nAMD in the at-risk fellow eyes of patients with unilateral nAMD, compared to clinical diagnosis. Given its relative inexpensiveness, ease of use and the inherent connectivity of the platforms it can be presented on, it may have a role in early detection of nAMD in the population at large.

Probing oculomotor inhibition with the minimally delayed oculomotor response task.

The ability to not execute (i.e. to inhibit) actions is important for behavioural flexibility and frees us from being slaves to our immediate sensory environment. The antisaccade task is one of several used to investigate behavioural inhibitory control. However, antisaccades involve a number of important processes besides inhibition such as attention and working memory. In the minimally delayed oculomotor response (MDOR) task, participants are presented with a simple target step, but instructed to saccade not to the target when it appears (a prosaccade response), but when it disappears (i.e. on target offset). Varying the target display duration prevents offset timing being predictable from the time of target onset, and saccades prior to the offset are counted as errors. Antisaccade error rate and latency are modified by alterations in fixation conditions produced by inserting a gap between fixation target offset and stimulus onset (the gap paradigm; error rate increases, latency decreases) or by leaving the fixation target on when the target appears (overlap paradigm; error rate decreases, latency increases). We investigated the effect of gaps and overlaps on performance in the MDOR task. In Experiment 1 we confirmed that, compared to a control condition in which participants responded to target onsets, in the MDOR task saccade latency was considerably increased (increases of 122-272 ms depending on target display duration and experimental condition). However, there was no difference in error rate or saccade latency between gap and synchronous (fixation target offset followed immediately by saccade target onset) conditions. In Experiment 2, in a different group of participants, we compared overlap and synchronous conditions and again found no statistically significant differences in error rate and saccade latency. The timing distribution of errors suggested that most were responses to target onsets, which we take to be evidence of inhibition failure. We conclude that the MDOR task evokes behaviour that is consistent across different groups of participants. Because it is free of the non-inhibitory processes operative in the antisaccade task, it provides a useful means of investigating behavioural inhibition.

Express saccades in distinct populations: east, west, and in-between.

Express saccades are low latency (80-130 ms), visually guided saccades. While their occurrence is encouraged by the use of gap tasks (the fixation target is extinguished 200 ms prior to the saccade target appearing) and suppressed by the use of overlap tasks (the fixation target remains present when the saccade target appears), there are some healthy, adult participants, "express saccade makers" (ESMs), who persist in generating high proportions (> 30%) of express saccades in overlap conditions. These participants are encountered much more frequently in Chinese participant groups than amongst the Caucasian participants tested to date. What is not known is whether this high number of ESMs is only a feature of Chinese participant groups. More broadly, there are few comparative studies of saccade behaviour across large participant groups drawn from different populations. We, therefore, tested an independent group of 70 healthy adult Egyptian participants, using the same equipment and procedures as employed in the previous studies. Each participant was exposed to two blocks of 200 gap, and two blocks of 200 overlap trials, with block order counterbalanced. Results from the Schwartz Value Survey were used to confirm that this group of participants was culturally distinct from the Chinese and Caucasian (white British) groups tested previously. Fourteen percent (10/70) of this new group were ESMs, and the pattern of latency distribution in these ESMs was identical to that identified in the other participant groups, with a prominent peak in the express latency range in overlap conditions. Overall, we identified three modes in the distribution of saccade latency in overlap conditions, the timing of which (express peak at 110 ms, subsequent peaks at 160 and 210 ms) were strikingly consistent with our previous observations. That these behavioural patterns of saccade latency are observed consistently in large participant groups, drawn from geographically, ethnically, and culturally distinct populations, suggests that they relate to the underlying architecture of the saccade system.

Performance, usability and comparison of two versions of a new macular vision test: the handheld Radial Shape Discrimination test.

BACKGROUND: Central vision, critical for everyday tasks such as reading and driving, is impacted by age-related changes in the eye and by diseases such as age-related macular degeneration. The detection of changes in macular function is therefore important. The Radial Shape Discrimination (RSD) test measures the threshold at which distortions in a radial frequency pattern can be detected and there is evidence that it is more sensitive to macular pathology than visual acuity (VA). It also provides a more quantitative measure of macular function than the commonly available Amsler grid. Recently, handheld versions of the test (hRSD) in which stimuli are presented on mobile devices (e.g., Apple iPod Touch, iPhone) have been developed. We investigated the characteristics of the hRSD test in healthy participants. METHODS: Data were collected using both three-alternative forced choice (3AFC) and 4AFC versions of the hRSD test, presented on an Apple iPod Touch. For the 3AFC version, data from a single test session were available for 186 (72 male; mean ± SD age 42 ± 17y; range 16-90y) healthy participants. Test-retest data were available for subgroups of participants (intra-session: N = 74; tests approximately 2 months apart: N = 30; tests 39 months apart: N = 15). The 3AFC and 4AFC versions were directly compared in 106 participants who also completed a usability questionnaire. Distance and near VA and Pelli Robson Contrast Sensitivity (CS) data were collected and undilated fundoscopy performed on the majority of participants. RESULTS: Mean (±SD) 3AFC hRSD threshold was -0.77 ± 0.14 logMAR, and was statistically significantly correlated with age (Pearson r = 0.35; p < 0.001). The linear regression of hRSD threshold on age had a slope of +0.0026 compared to +0.0051 for near VA (which also correlated with age: r = 0.51; p < 0.001). There were no statistically significant differences in hRSD thresholds for any of the test-retest subgroups. We also observed no statistically significant difference between 3AFC (-0.82 ± 0.11 logMAR) and 4AFC (-0.80 ± 0.12 logMAR) hRSD thresholds (t = 1.85, p = 0.067) and participants reported excellent test usability with no strong preference expressed between the 3AFC and 4AFC versions of the test. DISCUSSION: The 3AFC hRSD thresholds we report are consistent with a number of previous studies, as is its greater stability in ageing compared to VA. We have also shown that in the absence of pathology, thresholds are stable over short and long timescales. The 4AFC thresholds we have reported provide a baseline for future investigations, and we have confirmed that 3AFC and 4AFC thresholds are similar, providing a basis of comparisons between studies using the different versions. As the hRSD test is easy to use and relatively inexpensive, clinical studies are now required to establish its ability to detect and monitor macular pathologies.

Longitudinal Visuomotor Development in a Malaria Endemic Area: Cerebral Malaria and Beyond.

Paediatric cerebral malaria is the most serious complication of Plasmodium falciparum infection. While the majority recover, long-term cognitive impairment has been highlighted as a significant and neglected problem. Persistent or serious deficits in processes such as attention or behavioural inhibition should be manifest in changes to performance on oculomotor tasks. Therefore we investigated the impact of cerebral malaria on the development of reflexive pro-saccades and antisaccades. In a longitudinal study, 47 children previously admitted with retinopathy-confirmed cerebral malaria (mean age at admission 54 months), were compared with 37 local healthy controls (mean ages at first study visit 117 and 110 months respectively). In each of three or four test sessions, over a period of up to 32 months, participants completed 100 prosaccade tasks and 100 antisaccade tasks. Eye movements were recorded using infrared reflectance oculography; prosaccade, correct antisaccade and error prosaccade latency, and antisaccade directional error rate were calculated. Hierarchical linear modelling was used to investigate the effect of age and the influence of cerebral malaria on these parameters. Data were also collected from an independent, older group (mean age 183 months) of 37 local healthy participants in a separate cross-sectional study. Longitudinal data exhibited the expected decrease in latency with age for all saccade types, and a decrease in the antisaccade directional error rate. Hierarchical linear modelling confirmed that age had a statistically significant effect on all parameters (p< = 0.001). However, there were no statistically significant differences between the cerebral malaria and control groups. Combining groups, comparison with the literature demonstrated that antisaccade directional error rate for the Malawi sample was significantly higher than expected, while latencies for all saccade types were indistinguishable from published. The high directional error rate was also confirmed in the older, healthy Malawian participants from the cross sectional study. Our observation of similar oculomotor performance in cerebral malaria and control groups at long follow-up periods suggests that cerebral malaria survivors are not at a generally increased risk of persistent cognitive deficits. Our data raise questions about the prevailing hypothesis that cerebral malaria has gross impacts on the development of processes such as attention and behavioural inhibition. More importantly, our novel finding of a clear difference in antisaccade performance between all of the Malawi participants and published data suggests that the Malawian paediatric population as a whole faces serious challenges to cognitive development beyond cerebral malaria.

Resilience and vision impairment in older people.

Some people fare better than others when faced with adversity; they appear to be more 'resilient'. This article explores the concept of resilience in the context of vision impairment using two linked sets of narrative interview data from 2007 to 2010. Three case studies were analysed in detail using a framework approach based upon a social-ecological model of resilience and vision impairment. Within the model a range of assets and resources are identified which influence an individual's capacity for resilience. A set of criteria were used to establish the extent to which each individual appeared to be resilient at each point in time. Analysis revealed that it is not merely the presence or absence of individual, social, and community resources - but how these resources interact with each other - that influences resilience and can create a risk to wellbeing. To possess only some of these resources is not sufficient; there is a co-dependency between these resources which requires the presence of other resources for resilience to be achieved. Resilience is not a fixed state; individuals can become more or less resilient as their circumstances and resources change over time. We suggest that the concept of resilience has much to offer the field of vision impairment as it allows the identification of enablers as well as areas of barriers to improving people's health and wellbeing and suggests further opportunities for service providers to engage with clients, even those who appear to be supported, as people's social, economic and emotional landscapes continue to change over time, rather than identifying deficit.

Temporal stability and the effects of training on saccade latency in "express saccade makers".

The temporal stability of saccade latency, and the effects of training, particularly in "express saccade makers" (ESMs), has received little attention. ESMs are healthy, naïve, adults, who persist in executing very many low latency "express saccades" (ES; saccades with latency of 80 ms to 130 ms), in conditions designed to suppress such responses. We investigated the stability of ES production (%ES) in 59 ESM and 54 non-ESM participants in overlap tasks. Within a single session, the intraclass correlation coefficient (ICC) for %ES in two runs of 200 trials was 0.97 (p<0.001); participants in whom >30% of saccades over the two runs were ES, were classified as ESMs. For 60 participants tested over two sessions 12 weeks apart, and 30 participants tested in three sessions over approximately six months, the ICC for %ES was uniformly high (0.95, p<0.001 and 0.97, p<0.001 respectively) and participants behaved consistently with their initial classification. Fourteen participants (7 ESMs) were then exposed to training consisting of either gap or overlap tasks. Training increased %ES in both groups. However, when tested in overlap tasks, it was not sufficient to transform Normal participants into ESMs. We conclude that the pattern of saccade behaviour exhibited by ESMs constitutes a stable and distinct oculomotor phenotype.

Assessment of visual distortions in age-related macular degeneration: emergence of new approaches.

AIMS: With the arrival of effective treatments for neovascular age-related macular degeneration (nvAMD) there is a need to find improved tests that would allow early detection. Ideally, these tests would allow monitoring of vision by patients themselves from home. The aim of this review is to discuss the available evidence for two recently developed vision tests designed for this purpose: the Preferential Hyperacuity Perimeter (PHP) test and the Radial Shape Discrimination (RSD) test. METHODS: Articles that investigated detection of nvAMD were reviewed. The methodology of the clinical evidence, where available, was judged for bias and applicability of the results to the general population using the QUADAS-2 quality assessment tool. RESULTS: The PHP test has proved to be good at detecting nvAMD but many studies assessed in this review were biased in the selection of patients, restricting the results to only those patients who can use the test and produce reliable results. On the other hand the RSD test is a simple test, well accepted by elderly patients with AMD. However, clinical studies to determine its value in the detection of early signs of nvAMD are still required. CONCLUSIONS: To date, more studies have investigated the utility of the PHP test compared with the RSD test for detection of nvAMD. Both tests show promise but further evidence is needed to determine the real generalisability of the PHP test and the sensitivity of the RSD test.

Oculomotor inhibitory control in express saccade makers.

Express saccade makers (ESMs) produce high proportions (>30 %) of low-latency (80-130 ms) express saccades in tasks in which such responses are usually suppressed. In addition, high directional error rates on the antisaccade (AS) task suggest a failure of oculomotor inhibitory mechanisms in ESMs. However, the AS task is complex and does not provide a measure of inhibitory processes in isolation. We therefore examined inhibitory control in 25 ESM and 28 non-ESM ('Norm') participants, using a minimally delayed oculomotor response (MDOR) task. After a randomised fixation period, a pro-saccade target appeared for 200 or 1,000 ms. Participants were instructed to maintain fixation and saccade to the target position upon target offset. In a control task, they saccaded on target onset. Overall, saccade latency was considerably increased in the MDOR task compared to the control task (354 vs. 170 ms; p < 0.001), and we also observed a latency modulation with display time (200: 399, 1,000: 302 ms; p < 0.001). However, there was no evidence of a difference between groups (p = 0.29). Errors consisted primarily of responses to target onsets and error rates were comparable between the groups (p = 0.33). The overproduction of fast, reflexive responses was still observed in ESMs who generated a higher proportion of their errors within the express latency range (p < 0.001). We confirmed that in the AS task, the ESMs exhibited a higher directional error rate (p = 0.03). These results suggest that the performance 'deficit' observed on the AS task in ESMs cannot be attributed to generally weaker inhibitory control.

Cultural diversity and saccade similarities: culture does not explain saccade latency differences between Chinese and Caucasian participants.

A central claim of cultural neuroscience is that the culture to which an individual belongs plays a key role in shaping basic cognitive processes and behaviours, including eye movement behaviour. We previously reported a robust difference in saccade behaviour between Chinese and Caucasian participants; Chinese participants are much more likely to execute low latency express saccades, in circumstances in which these are normally discouraged. To assess the extent to which this is the product of culture we compared a group of 70 Chinese overseas students (whose primary cultural exposure was that of mainland China), a group of 45 participants whose parents were Chinese but who themselves were brought up in the UK (whose primary cultural exposure was western European) and a group of 70 Caucasian participants. Results from the Schwartz Value Survey confirmed that the UK-Chinese group were culturally similar to the Caucasian group. However, their patterns of saccade latency were identical to the mainland Chinese group, and different to the Caucasian group. We conclude that at least for the relatively simple reflexive saccade behaviour we have investigated, culture cannot explain the observed differences in behaviour.