Keratoconus and the Impact of Treatment on Patients' Quality of Life: A Qualitative Study.

INTRODUCTION: Keratoconus has a significant impact on patients' quality of life (QoL), from diagnosis to the advanced stages of the disease. The aim of this research was to identify domains of QoL affected by this disease and its treatment. METHODS: Phone interviews were conducted using a semi-structured interview guide, with patients with keratoconus stratified according to their current treatment. A board of keratoconus experts helped identify the guide's main themes. RESULTS: Thirty-five patients (rigid contact lenses, n = 9; cross-linking, n = 9; corneal ring implants, n = 8; and corneal transplantation, n = 9) were interviewed by qualitative researchers. Phone interviews revealed several QoL domains affected by the disease and its treatments: "psychological", "social life", "professional life", "financial costs" and "student life". All domains were impacted, independently of the treatment history. Few differences were found between treatment regimens and keratoconus stages. Qualitative analysis enabled the development of a conceptual framework based on Wilson and Cleary's model for patient outcomes common to all patients. This conceptual model describes the relationship between patients' characteristics, their symptoms, their environment, their functional visual impairment and the impact on their QoL. CONCLUSIONS: These qualitative findings supported the generation of a questionnaire to evaluate the impact of keratoconus and its treatment on patients' QoL. Cognitive debriefings confirmed its content validity. The questionnaire is applicable for all stages of keratoconus and treatments and may help tracking change over time in regular clinical settings. Psychometric validation is yet to be performed before its use in research and clinical practices.

24-Hour Monitoring of Intraocular Pressure Fluctuations Using a Contact Lens Sensor: Diagnostic Performance for Glaucoma Progression.

Purpose: The purpose of this study was to compare 24-hour intraocular pressure (IOP) related fluctuations monitoring between 2 groups of visual field progression rates in patients with open angle glaucoma (OAG). Methods: Cross-sectional study performed at Bordeaux University Hospital. Twenty-four-hour monitoring was performed using a contact lens sensor (CLS; Triggerfish; SENSIMED, Etagnières, Switzerland). Progression rate was calculated using a linear regression of the mean deviation (MD) parameter of the visual field test (Octopus; HAAG-STREIT, Switzerland). Patients were allocated into two groups: group 1 with an MD progression rate <-0.5 dB/year and group 2 with an MD progression rate ≥-0.5 dB/year. An automatic signal-processing program was developed and a frequency filtering of the monitoring by wavelet transform analysis was used to compare the output signal between the two groups. A multivariate classifier was performed for prediction of the faster progression group. Results: Fifty-four eyes of 54 patients were included. The mean progression rate was -1.09 ± 0.60 dB/year in group 1 (n = 22) and -0.12 ± 0.13 dB/year in group 2 (n = 32). Twenty-four-hour magnitude and absolute area under the monitoring curve were significantly higher in group 1 than in group 2 (group 1: 343.1 ± 62.3 millivolts [mVs] and 8.28 ± 2.10 mVs, respectively, group 2: 274.0 ± 75.0 mV and 6.82 ± 2.70 mVs respectively, P < 0.05). Magnitude and area under the wavelet curve for short frequency periods ranging from 60 to 220 minutes were also significantly higher in group 1 (P < 0.05). Conclusions: The 24-hour IOP related fluctuations characteristics, as assessed by a CLS, may act as a risk factor for progression in OAG. In association with other predictive factors of glaucoma progression, the CLS may help adjust treatment strategy earlier.

Global trends in myopia management attitudes and strategies in clinical practice - 2019 Update.

PURPOSE: A survey in 2015 identified a high level of eye care practitioner concern about myopia with a reported moderately high level of activity, but the vast majority still prescribed single vision interventions to young myopes. This research aimed to update these findings 4 years later. METHODS: A self-administrated, internet-based questionnaire was distributed in eight languages, through professional bodies to eye care practitioners globally. The questions examined: awareness of increasing myopia prevalence, perceived efficacy of available strategies and adoption levels of such strategies, and reasons for not adopting specific strategies. RESULTS: Of the 1336 respondents, concern was highest (9.0 ±â€¯1.6; p < 0.001) in Asia and lowest (7.6 ±â€¯2.2; p < 0.001) in Australasia. Practitioners from Asia also considered their clinical practice of myopia control to be the most active (7.7 ±â€¯2.3; p < 0.001), the North American practitioners being the least active (6.3 ±â€¯2.9; p < 0.001). Orthokeratology was perceived to be the most effective method of myopia control, followed by pharmaceutical approaches and approved myopia control soft contact lenses (p < 0.001). Although significant intra-regional differences existed, overall, most practitioners did not consider single-vision distance under-correction to be an effective strategy for attenuating myopia progression (79.6 %), but prescribed single vision spectacles or contact lenses as the primary mode of correction for myopic patients (63.6 ±â€¯21.8 %). The main justifications for their reluctance to prescribe alternatives to single vision refractive corrections were increased cost (20.6 %) and inadequate information (17.6 %). CONCLUSIONS: While practitioner concern about myopia and the reported level of activity have increased over the last 4 years, the vast majority of eye care clinicians still prescribe single vision interventions to young myopes. With recent global consensus evidence-based guidelines having been published, it is hoped that this will inform the practice of myopia management in future.

Autofluorescence of Skin Advanced Glycation End Products as a Risk Factor for Open Angle Glaucoma: The ALIENOR Study.

Purpose: To analyze the association between skin autofluorescence (sAF), estimating tissue accumulation of advanced glycation end-products (AGEs), and open angle glaucoma (OAG) in an elderly population. Methods: The Antioxydants, Lipides Essentiels, Nutrition and maladies OculaiRes (ALIENOR) study is an on-going epidemiologic population-based study on age-related eye diseases. In 2009 to 2010, 624 subjects, aged 74 years or older, were recruited. All subjects underwent a complete eye examination, including optic disc color photography and spectral-domain optical coherence tomography (SD-OCT) examination. Sociodemographic and medical history data were collected using standardized questionnaires. Glaucoma diagnosis was made using optic nerve head retinophotography and International Society for Epidemiologic and Geographical Ophthalmology criteria. sAF was measured with a noninvasive autofluorescence reader in 467 subjects. Results: Of subjects, 455 had complete data, 424 were classified as controls, and 31 classified as OAG. Mean age was 82.3 ± 4.3 years, mean and median sAF were 2.8 ± 0.7 and 2.7 arbitrary units (AU), respectively. In a multivariate analysis, higher sAF values (≥2.7 AU) were associated with OAG (odds ratio [OR] = 2.28, 95% Confidence Interval [CI]: 1.03; 5.04). Other variables significantly associated with OAG were age (OR = 1.10, 95%CI: 1.00; 1.21), glaucoma family history (OR = 2.83, 95%CI: 1.14; 7.01) and smoking (1-20 pack-years [OR = 3.31, 95%CI: 1.18; 9.26]; ≥20 pack-years [OR = 3.85, 95%CI: 1.42; 10.46]). Conclusions: Higher level of sAF, which may act as a long-term biomarker of metabolic memory, and smoking are independently associated with an increased risk of glaucoma. Long-term accumulation of AGEs, a marker of oxidative stress, could play a role in the pathogenesis of glaucomatous chronic optic neuropathy.

TFOS DEWS II Epidemiology Report.

The subcommittee reviewed the prevalence, incidence, risk factors, natural history, morbidity and questionnaires reported in epidemiological studies of dry eye disease (DED). A meta-analysis of published prevalence data estimated the impact of age and sex. Global mapping of prevalence was undertaken. The prevalence of DED ranged from 5 to 50%. The prevalence of signs was higher and more variable than symptoms. There were limited prevalence studies in youth and in populations south of the equator. The meta-analysis confirmed that prevalence increases with age, however signs showed a greater increase per decade than symptoms. Women have a higher prevalence of DED than men, although differences become significant only with age. Risk factors were categorized as modifiable/non-modifiable, and as consistent, probable or inconclusive. Asian ethnicity was a mostly consistent risk factor. The economic burden and impact of DED on vision, quality of life, work productivity, psychological and physical impact of pain, are considerable, particularly costs due to reduced work productivity. Questionnaires used to evaluate DED vary in their utility. Future research should establish the prevalence of disease of varying severity, the incidence in different populations and potential risk factors such as youth and digital device usage. Geospatial mapping might elucidate the impact of climate, environment and socioeconomic factors. Given the limited study of the natural history of treated and untreated DED, this remains an important area for future research.

Vision-related quality of life and dependency in French keratoconus patients: Impact study.

PURPOSE: To assess the quality of life in French keratoconus patients. SETTING: Fifty-seven Keratoconus National Reference Centers across France. DESIGN: Prospective case series. METHODS: Patients completed the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) and a French validated questionnaire on disability and dependency from February to June 2012 when they came for an ophthalmic examination at 57 participating centers across France. An ocular examination including refraction, corneal topography, pachymetry, and slitlamp biomicroscopy was performed. The composite or global NEI VFQ-25 score and the proportion of patients who were dependent (defined by the difficulties with activities of daily living) because of keratoconus were the main evaluation criteria in this study. RESULTS: The study comprised 550 keratoconus patients. Women, corrected distance visual acuity worse than 20/40, steep keratometry higher than 52.0 diopters, history of surgery (corneal transplant, intrastromal corneal ring segments, or corneal crosslinking), and more severe keratoconus according to the Amsler-Krumeich classification were associated with an increasingly negative impact on quality of life (overall scores are significantly lower). Moreover, 4.9% of participants reported having changed their jobs because of keratoconus and 7.8% received keratoconus-related disability. Sixty-nine (12.5%) patients reported having difficulties with activities of daily living and are considered dependent. CONCLUSION: Keratoconus was associated with a significant reduction in quality of life but it did not result in social exclusion.

Optic Radiations Microstructural Changes in Glaucoma and Association With Severity: A Study Using 3Tesla-Magnetic Resonance Diffusion Tensor Imaging.

Purpose: To compare microstructural changes along the optical radiations and brain structure volumes between glaucoma and control subjects using in vivo magnetic resonance imaging and to analyze their association with severity of the disease. Methods: A total of 50 open-angle glaucoma subjects and 50 healthy age- and sex-matched controls underwent detailed ophthalmologic examinations (including visual field testing [VF], funduscopy, and spectral-domain optical coherence tomography) as well as diffusion tensor imaging (DTI) using 3.0-Tesla magnetic resonance imaging. Fractional anisotropy (FA), mean diffusivity, radial diffusivity (RD), and axial diffusivity (AD) were quantified semiautomatically along the optical radiations. DTI parameters and volumes of specific brain structures were compared between cases and controls using conditional logistic regression. Association between DTI metrics and the severity of the disease was studied using linear mixed regression analyses. Results: In glaucoma subjects, optic radiations FA was significantly lower (0.57 vs. 0.59; P = 0.02) and RD was significantly higher (52.78 10-5 mm2/s vs. 49.74 10-5 mm2/s; P = 0.03) than in controls. Optic radiations FA was significantly correlated with homolateral functional and structural damage of glaucoma (mean deviation of VF [P = 0.03], retinal nerve fiber layer thickness [P = 0.03], vertical cup to disc ratio [P = 0.0007]). Volume and DTI parameters of other brain structures (including hippocampus) were not significantly different between glaucoma patients and controls. Conclusions: We evidenced microstructural modifications along visual pathways of glaucoma patients and these alterations were correlated with disease severity. The association of glaucoma with other neurodegenerative alterations would need further exploration and a prospective follow-up of our cohort of subjects. (ClinicalTrials.gov number, NCT01621841).

Diagnostic Performance of Peripapillary Retinal Nerve Fiber Layer Thickness for Detection of Glaucoma in an Elderly Population: The ALIENOR Study.

PURPOSE: To assess diagnostic accuracy of spectral-domain optical coherence tomography (SD-OCT) to discriminate glaucoma and control subjects in an elderly population. METHODS: The antioxidants, essential lipids, nutrition and ocular maladies study (ALIENOR: "Antioxydants, Lipides Essentiels, Nutrition et Maladies Oculaires") is a population-based study. From 2009 to 2010, a total of 624 subjects, aged 74 years or older underwent a complete eye examination, including optic disc color photography and SD-OCT examination of the macula and the optic nerve head. Glaucoma diagnosis was made using retinophotography of the optic nerve head and International Society for Epidemiologic and Geographical Ophthalmology criteria. Average and sectorial peripapillary retinal nerve fiber layer thicknesses (RNFLT) were compared between glaucoma and control subjects using area under the receiver operating characteristic curves (AUC), positive and negative likelihood ratios (LR+/LR-), and diagnostic odds ratios (DOR). RESULTS: A total of 532 subjects had complete data, 492 were classified as controls and 40 were classified as glaucoma. Mean age was 82.1 ± 4.2 years and average RNFLT was significantly different between both groups (controls: 88.7 ± 12.2 µm, glaucoma: 65.4 ± 14.4 µm, P < 0.001). Highest AUC values were observed for average (0.895), temporal-inferior (0.874), and temporal-superior (0.868) RNFLT. Temporal-superior RNFLT had the highest DOR (25.31; LR+, 4.65; LR-, 0.18), followed by average RNFLT (DOR: 24.80; LR+, 6.36; LR-, 0.26). When using the normative database provided by the machine, DOR increased to 31.03 (LR+, 1.75; LR-, 0.06) if at least one parameter was considered abnormal (at P < 0.05). CONCLUSIONS: Parameters of SD-OCT RNFL may provide valuable information in a screening strategy to improve glaucoma detection in a general population of elderly people.

Associations of Biomechanical Properties of the Cornea With Environmental and Metabolic Factors in an Elderly Population: The ALIENOR Study.

PURPOSE: The purpose of this study was to assess the associations of biomechanical properties of the cornea with metabolic and environmental factors in an elderly population. METHODS: The ALIENOR (Antioxydants, Lipides Essentiels, Nutrition, and Maladies OculaiRes) study is a population-based study. In 2009-2010, 624 subjects, aged 74 years or more, underwent an eye examination, including intraocular pressure (IOP), central corneal thickness (CCT), and biomechanical properties of the cornea measurements using the Ocular Response Analyzer. Socio-demographic, lifestyle, and medical history data were collected using standardized questionnaires. Mean lifetime ambient ultraviolet (UV) exposure was estimated using residential history and statistics of UV radiation at each location using the Eurosun UV database. RESULTS: Mean age was 82.2 ± 4.3 years. Mean corneal hysteresis (CH), corneal resistance factor (CRF), and CCT were 9.4 ± 1.9, 9.8 ± 1.9 mm Hg, and 551.6 ± 36.8 µm, respectively. In the multivariate analysis, CH and CRF values were significantly lower in subjects older than 80 years (-0.56; 95% confidence interval [CI]: -0.89; -0.24); P < 0.001 and -0.48; 95% CI: -0.75;-0.20; P < 0.001, respectively), in subjects having higher ambient UV exposure (-0.50; 95% CI: -0.88; -0.12; P < 0.01; and -0.46; 95% CI: -0.78; -0.13); P < 0.05, respectively), and in subjects with high plasma LDL cholesterol (CH: -0.46; 95% CI: -0.86; -0.03; P < 0.05; and CRF: -0.37; 95% CI: -0.72; -0.008; P < 0.05). Central corneal thickness was significantly higher in former smokers than in never smokers (+11.01; 95% CI: 0.48; 21.55; P < 0.05) and was not significantly associated with age, ambient UV exposure, diabetes, or LDL cholesterol. CONCLUSIONS: Biomechanical properties of the cornea are modified by metabolic and lifetime environmental factors, especially UV exposure. The manner these factors may influence onset and progression of ocular diseases or IOP measurements need further investigation.

Global trends in myopia management attitudes and strategies in clinical practice.

PURPOSE: Myopia is a global public health issue; however, no information exists as to how potential myopia retardation strategies are being adopted globally. METHODS: A self-administrated, internet-based questionnaire was distributed in six languages, through professional bodies to eye care practitioners globally. The questions examined: awareness of increasing myopia prevalence, perceived efficacy and adoption of available strategies, and reasons for not adopting specific strategies. RESULTS: Of the 971 respondents, concern was higher (median 9/10) in Asia than in any other continent (7/10, p<0.001) and they considered themselves more active in implementing myopia control strategies (8/10) than Australasia and Europe (7/10), with North (4/10) and South America (5/10) being least proactive (p<0.001). Orthokeratology was perceived to be the most effective method of myopia control, followed by increased time outdoors and pharmaceutical approaches, with under-correction and single vision spectacles felt to be the least effective (p<0.05). Although significant intra-regional differences existed, overall most practitioners 67.5 (±37.8)% prescribed single vision spectacles or contact lenses as the primary mode of correction for myopic patients. The main justifications for their reluctance to prescribe alternatives to single vision refractive corrections were increased cost (35.6%), inadequate information (33.3%) and the unpredictability of outcomes (28.2%). CONCLUSIONS: Regardless of practitioners' awareness of the efficacy of myopia control techniques, the vast majority still prescribe single vision interventions to young myopes. In view of the increasing prevalence of myopia and existing evidence for interventions to slow myopia progression, clear guidelines for myopia management need to be established.

Retinal nerve fibre layer thickness measured with SD-OCT in a population-based study of French elderly subjects: the Alienor study.

PURPOSE: To establish normative data of retinal nerve fibre layer (RNFL) thickness in the elderly and to determine the factors influencing its thickness. METHODS: Peripapillary RNFL thickness was measured with spectral domain OCT (SD-OCT) in 210 elderly participants from the Alienor population-based study who were aged 75 years or older. The measure was assessed in six segments (the superotemporal, temporal, inferotemporal, inferonasal, nasal and superonasal segments). RNFL data were analysed across age and sex strata in non-glaucoma participants. Mixed linear models were used to evaluate the associations of RNFL thickness with age, sex, ocular parameters and vascular risk factors. RESULTS: The mean global RNFL thickness was 91.4 µm (SD: 12.6), ranging from 55 to 122; the highest values were found in the inferotemporal and superotemporal segments. After adjustment for sex and ocular parameters, including axial length, increasing age was significantly associated with lower thickness globally (mean thinning per decade = 5.6 µm, p = 0.003), in the superotemporal (-12.7 µm per decade, p < 0.0001) and inferotemporal (-8.1 µm per decade, p = 0.022) segments. RNFL thickness tended to be higher in women than in men, but this trend was significant only in the inferotemporal segment (+6.6 µm for women, p = 0.012). The axial length was associated with RNFL thickness globally and in most segments. RNFL thickness did not differ according to cataract extraction. There were no associations between vascular factors and RNFL thickness. CONCLUSION: Retinal nerve fibre layer thickness decreased with age globally and in the supero- and inferotemporal segments, even after 75 years; it also tended to be higher in women, particularly in the inferotemporal segment. Normative data on RNFL thickness should consider these characteristics as well as ocular parameters, particularly axial length.

An acute clinical comparison of corneal staining and comfort associated with contact lens care solutions.

PURPOSE: This study compared the biocompatibility and comfort of 4 lens care solutions currently marketed in France. METHODS: This was a randomized, interventional, double-masked, single-center crossover study assessing balafilcon A silicone hydrogel contact lenses, bilaterally, straight from the blister pack solution (control) and pre-soaked in the following lens care solutions: Regard(®) (containing sodium chlorite), ReNu(®) (containing a PHMB [polyhexamethylene biguanide] derivative), CyClean™ and MeniCare™ Soft (both containing PHMB). Subjects were randomized to the order of test solution use. For each of the 5 solutions tested, subjects attended a baseline/lens dispensing visit and an intervention visit 2h later. At both visits, evaluation included slit-lamp examination, corrected-distance visual acuity, corneal staining, and subject-assessed photophobia, ocular comfort, and ocular redness. RESULTS: Thirty subjects were enrolled and 28 were evaluable. Corneal staining severity was significantly worse than baseline after 2h of wearing lenses soaked in CyClean, MeniCare, or ReNu (P≤0.001). The MeniCare group alone demonstrated a significant improvement in ocular comfort after 2h of lens wear (P=0.02). No group demonstrated significant changes in ocular redness or photophobia. Corrected-distance visual acuity was similar between baseline and intervention visits for each test solution. No adverse events were reported during the study. CONCLUSIONS: Silicone hydrogel contact lenses presoaked in lens solutions containing PHMB or a PHMB derivative produced an increase in corneal staining after 2h of lens wear. The higher levels of corneal staining in the 2 solutions did not correlate with increased discomfort within this 2-h timeframe.

Dry eye disease in French elderly subjects: the Alienor Study.

PURPOSE: To describe dry eye disease in French elderly subjects. METHODS: The Alienor Study is a population-based study on age-related eye disease in 963 residents of Bordeaux (France), aged 73 years or more. Self-reported dry eye disease and use of artificial tears were documented through face-to-face interview. Dry eye symptoms were assessed using the Ocular Surface Disease Index (OSDI) questionnaire and tear film stability by tear break-up time measurements (TBUT). Definite dry eye disease was defined as self-reported dry eye, confirmed by use of artificial tears and/or OSDI greater or equal to 22. RESULTS: Nine hundred and fifteen subjects, with mean age of 80 ± 4 years, returned the OSDI questionnaire. Of these, 271 (29.6%) subjects reported a dry eye disease and 135 (14.7%) were using artificial tears. An OSDI score > 22 was found in 359 (39.2%) subjects and a TBUT < 5 seconds in 335/746 (44.9%) subjects. Overall, definite dry eye affected 21.9% of subjects and was more frequent in women (27.1%) than in men (13.6%). After multivariate adjustment, dry eye disease was also significantly less frequent in subjects with high educational level (odds ratio (OR) = 0.49, 95% confidence interval (CI): 0.31-0.78 for long secondary school) and more frequent in subjects with ocular hypertension (OR = 1.61, 95% CI: 1.02-2.57) and those using anxiolytics (OR = 1.53, 95% CI: 1.02-2.29). CONCLUSIONS: This large observational study confirmed the high prevalence of dry eye symptoms among elderly subjects and confirmed some of the previously identified risk factors (in particular female gender and use of anxiolytics).

Association of HDL-related loci with age-related macular degeneration and plasma lutein and zeaxanthin: the Alienor study.

BACKGROUND: Several genes implicated in high-density lipoprotein (HDL) metabolism have been reported to be associated with age-related macular degeneration (AMD). Furthermore, HDL transport the two carotenoids, lutein and zeaxanthin, which are highly suspected to play a key-role in the protection against AMD. The objective is to confirm the associations of HDL-related loci with AMD and to assess their associations with plasma lutein and zeaxanthin concentrations. METHODS: Alienor study is a prospective population-based study on nutrition and age-related eye diseases performed in 963 elderly residents of Bordeaux, France. AMD was graded according to the international classification, from non-mydriatic colour retinal photographs. Plasma lutein and zeaxanthin were determined by normal-phase high-performance liquid chromatography. The following polymorphisms were studied: rs493258 and rs10468017 (LIPC), rs3764261 (CETP), rs12678919 (LPL) and rs1883025 (ABCA1). RESULTS: After multivariate adjustment, the TT genotype of the LIPC rs493258 variant was significantly associated with a reduced risk for early and late AMD (OR=0.64, 95%CI: 0.41-0.99; p=0.049 and OR=0.26, 95%CI: 0.08-0.85; p=0.03, respectively), and with higher plasma zeaxanthin concentrations (p=0.03), while plasma lipids were not significantly different according to this SNP. Besides, the LPL variant was associated with early AMD (OR=0.67, 95%CI: 0.45-1.00; p=0.05) and both with plasma lipids and plasma lutein (p=0.047). Associations of LIPC rs10468017, CETP and ABCA1 polymorphisms with AMD did not reach statistical significance. CONCLUSION: These findings suggest that LIPC and LPL genes could both modify the risk for AMD and the metabolism of lutein and zeaxanthin.

Is there a link between open-angle glaucoma and dementia? The Three-City-Alienor cohort.

OBJECTIVE: Previous research has suggested an association between dementia and glaucoma through common risk factors or mechanisms. Our aim was to evaluate the longitudinal relationship between open-angle glaucoma (OAG) and incident dementia. METHODS: The Three-City-Bordeaux-Alienor study is a population-based cohort of 812 participants with a 3-year follow-up period. All participants were aged 72 years or older. An eye examination was performed on all subjects. An OAG was determined based on optic nerve damage and visual field loss. Incident dementia was actively screened for and confirmed by a neurologist. RESULTS: A total of 41 participants developed dementia over the 3-year follow-up period. Future incident dementia cases had an increased prevalence of OAG (17.5% vs 4.5% for nondemented participants, p = 0.003). After adjustment for age, gender, education, family history of glaucoma, vascular comorbidities, and apolipoprotein ε4, our results showed that participants with an OAG were four times more likely to develop dementia during the 3-year follow-up period (odds ratio = 3.9, 95% confidence interval = 1.5-10.4, p = 0.0054). An increased risk of dementia was also associated with 2 markers of optic nerve degeneration (vertical cup:disk ratio and minimal rim:disk ratio). However, no association was found between a high intraocular pressure and/or the use of intraocular pressure-lowering medications and incident dementia. INTERPRETATION: If the association between OAG and dementia is confirmed, direct and noninvasive quantification of the amount of retinal ganglion cell axonal loss may be a useful biomarker of cerebral axonal loss in the future. It may also offer new breakthroughs in understanding the underlying pathophysiological mechanisms of both diseases.

Long-term blood pressure and age-related macular degeneration: the ALIENOR study.

PURPOSE: To explore the association of AMD with long-term average blood pressure (BP) parameters, including pulse pressure (PP). METHODS: The ALIENOR study is a population-based study on age-related eye diseases in 963 residents of Bordeaux, France, aged 73 years or older. AMD was graded from nonmydriatic color retinal photographs, in three exclusive stages: no AMD (1015 eyes), large soft distinct drusen and/or large soft indistinct drusen and/or reticular drusen and/or pigmentary abnormalities (early AMD, 276 eyes), and late AMD (66 eyes). BP parameters were measured at four occasions over a 7-year period. PP was defined as systolic BP minus diastolic BP. Associations of AMD with BP parameters were estimated using generalized estimating equation logistic regressions. Statistical analyses included 702 subjects (1357 eyes) with complete data. RESULTS: After adjustment for age, sex, educational level, smoking, body mass index, plasma HDL and LDL cholesterol, CFH Y402H, ApoE2, ApoE4, and ARMS2 A69S polymorphisms, elevated PP was significantly associated with an increased risk of late AMD (odds ratio [OR] = 1.37 for a 10-mm Hg increase, 95% confidence interval [CI]: 1.03-1.82). Associations were similar for late atrophic and late neovascular AMD (OR = 1.39, 95% CI: 1.01-1.92, P = 0.04, and OR = 1.43, 95% CI: 0.90-2.23, P = 0.13, respectively). Association with early AMD was in the same direction but did not reach statistical significance (OR = 1.12, 95% CI: 0.98-1.28). Early and late AMD were not significantly associated with systolic or diastolic BP, hypertension, or use of antihypertensive medications. CONCLUSIONS: This study suggests that high PP may be associated with increased risk for AMD.

High concentrations of plasma n3 fatty acids are associated with decreased risk for late age-related macular degeneration.

High dietary intakes of n3 (ω3) polyunsaturated fatty acids (PUFA) and fish have been consistently associated with a decreased risk for age-related macular degeneration (AMD). We assessed the associations of late AMD with plasma n3 PUFA, a nutritional biomarker of n3 PUFA status. The Antioxydants Lipides Essentiels Nutrition et Maladies Occulaires (Alienor) Study is a prospective, population-based study on nutrition and age-related eye diseases performed in 963 residents of Bordeaux (France) aged ≥73 y. Participants had a first eye examination in 2006-2008 and were followed for 31 mo on average. Plasma fatty acids were measured by GC from fasting blood samples collected in 1999-2001. AMD was graded from non-mydriatic color retinal photographs at all examinations and spectral domain optical coherence tomography at follow-up. After adjustment for age, gender, smoking, education, physical activity, plasma HDL-cholesterol, plasma triglycerides, CFH Y402H, apoE4, and ARMS2 A69S polymorphisms, and follow-up time, high plasma total n3 PUFA was associated with a reduced risk for late AMD [OR = 0.62 for 1-SD increase (95% CI: 0.44-0.88); P = 0.008]. Associations were similar for plasma 18:3n3 [OR = 0.62 (95% CI: 0.43-0.88); P = 0.008] and n3 long-chain PUFA [OR = 0.65 (95% CI: 0.46-0.92); P = 0.01]. This study gives further support to the potential role of n3 PUFAs in the prevention of late AMD and highlights the necessity of randomized clinical trials to determine more accurately the value of n3 PUFAs as a means of reducing AMD incidence.

Scalability and severity of keratoconus in children.

PURPOSE: To assess the severity of keratoconus at diagnosis and its scalability over a period of 2 years in children compared to adults. DESIGN: A retrospective monocentric study was conducted in the National Reference Center for Keratoconus, Bordeaux (France), between October 1997 and November 2010. METHODS: In total, 216 patients were studied, comprising 49 patients (22.7%) aged ≤ 15 and 167 patients (77.3%) aged ≥ 27 years at diagnosis, who were seen within 2 years of diagnosis. Severity at diagnosis was assessed using Krumeich's classification, and the scalability criteria of the US Food and Drug Administration (2010) were used. Student t tests and χ(2) tests were performed to compare the 2 groups. RESULTS: Keratoconus in children was significantly more severe at diagnosis, with 27.8% being stage 4 vs 7.8% of adults (P < .0001). In addition, ophthalmoscopic signs were more frequent in children (42.9% vs 29.5%, P = .05), while mean values of maximum, average, and minimum keratometry as well as simulated keratometric astigmatism were higher (P < .0001, P = .0002, P = .0005, and P = .001, respectively). After diagnosis, keratoconus did not evolve more frequently in children. However, in the case of progression, keratoconus evolved faster in children, with significant differences in the spherical equivalent and maximum and minimum keratometry (P = .03, P = .02, P = .04, respectively). CONCLUSION: At diagnosis, keratoconus is often more advanced in children than in adults, with faster disease progression. Early detection and close monitoring are therefore crucial in young patients.

Corneal confocal microscopy following conventional, transepithelial, and accelerated corneal collagen cross-linking procedures for keratoconus.

PURPOSE: To compare early corneal healing following conventional, transepithelial, and accelerated corneal collagen cross-linking (CXL) protocols. METHODS: Twenty-four patients with progressive keratoconus were divided into three groups to receive conventional, transepithelial, or accelerated CXL. In vivo corneal confocal microscopy was performed on each patient preoperatively and at 1, 3, and 6 months postoperatively. RESULTS: Closure of the epithelial wound was complete 3 days following conventional and accelerated CXL. The subbasal nerve plexus was essentially obliterated immediately following conventional and accelerated CXL, and virtually no nerve fibers had regenerated by 6 months. The anterior stroma showed significant changes 1 month following conventional CXL; these changes were similar but more pronounced following accelerated CXL. Observed stromal changes included complete obliteration of keratocytes, increased tissue reflectivity, a honeycomb-like appearance, and circular lacunae. Some recovery of keratocyte density was noted after 6 months. These changes were less pronounced in the mid-stroma, and there were no apparent changes to the posterior stroma or endothelium. The cornea appeared to be unaltered following transepithelial CXL. CONCLUSIONS: In vivo corneal confocal microscopy analysis of the postoperative impact of CXL on the cornea revealed clear differences among conventional, accelerated, and transepithelial CXL protocols. Accelerated CXL had a greater impact than conventional CXL on the anterior cornea, whereas transepithelial CXL did not appear to alter corneal morphology.