The incidence of falls after first and second eye cataract surgery: a longitudinal cohort study.

OBJECTIVE: To compare fall incidence, and visual acuity and refractive status, before surgery and after first and second eye cataract surgery. DESIGN, SETTING: Prospective observational study in eight tertiary referral ophthalmology clinics in public hospitals in Sydney, Melbourne, and Perth. PARTICIPANTS: People aged 65 years or more referred for bilateral age-related cataract surgery during 2013-16, followed for maximum of 24 months after study entry or until six months after second eye surgery, whichever was shorter. MAIN OUTCOME MEASURES: Primary outcome: age- and sex-adjusted incidence of falls. SECONDARY OUTCOMES: visual acuity and refractive error. RESULTS: The mean age of the 409 included participants was 75.4 years (SD, 5.4 years); 220 were women (54%). Age- and sex-adjusted fall incidence prior to surgery was 1.17 (95% CI, 0.95-1.43) per year, 0.81 (95% CI, 0.63-1.04) per year after first eye surgery, and 0.41 (95% CI, 0.29-0.57) per year after second eye surgery. For the 118 participants who underwent second eye surgery and participated in all follow-up visits, age- and sex-adjusted incidence before (0.80 [95% CI, 0.55-1.15] falls per year) and after first eye surgery (0.81 [95% CI, 0.57-1.15] falls per year) was similar, but was lower after second eye surgery (0.32 [95% CI 0.21-0.50] falls per year). Mean habitual binocular visual acuity (logMAR) was 0.32 (SD, 0.21) before surgery, 0.15 (SD, 0.17) after first eye surgery, and 0.07 (SD, 0.15) after second eye surgery. CONCLUSIONS: First eye surgery substantially improves vision in older people with cataract, but second eye surgery is required to minimise fall incidence. Timely cataract surgery for both eyes not only optimises vision in older people with cataract, but also reduces their risk of injury from falls.

Incidence and Outcomes of Infectious and Noninfectious Endophthalmitis after Intravitreal Injections for Age-Related Macular Degeneration.

PURPOSE: To assess the incidence, cumulative rate, and long-term outcomes of infectious and noninfectious endophthalmitis after intravitreal injections (IVTs) of anti-vascular endothelial growth factor (VEGF) agents. DESIGN: Database study, prospectively designed. PARTICIPANTS: Treatment-naïve eyes with neovascular age-related macular degeneration (nAMD) tracked by the Fight Retinal Blindness! (FRB!) registry that commenced anti-VEGF therapy between January 1, 2006, and November 30, 2016. METHODS: Cumulative rate of endophthalmitis and survival curves were measured using Cox-proportional hazards models. Locally weighted scatterplot smoothing curves were used to display visual acuity (VA). MAIN OUTCOME MEASURES: Incidence and cumulative rate of endophthalmitis, and change in VA 12 months after endophthalmitis. RESULTS: Infectious endophthalmitis developed in 18 of 88 150 injections (1/4897 injections [0.020%]; 95% confidence interval [CI], 0.012-0.032) with no difference found between types of anti-VEGF medications (P = 0.896). The cumulative rate of infectious endophthalmitis per patient was 0.055%, 0.183%, 0.360%, 0.360%, 0.555%, and 0.843% after 10, 20, 30, 40, 50, and 60 IVTs, respectively. However, the "risk" of infectious endophthalmitis did not increase with each successive injection (P = 0.202). Noninfectious endophthalmitis developed in 11 of 88 150 injections (1/8013 injections [0.012%]; 95% CI, 0.006-0.022). The cumulative rate of noninfectious endophthalmitis per patient was 0.087% and 0.228% after 10 and 20 IVTs, respectively, and then remained stable up to 60 IVTs. The incidence of noninfectious endophthalmitis was higher for bevacizumab (8/9931, 0.081%) compared with ranibizumab (3/54 776, 0.005%; P = 0.005) and aflibercept (0/23 425; P = 0.016), and no differences were observed between ranibizumab and aflibercept (P = 1.0). The 12-month VA in infectious and noninfectious endophthalmitis was within ±2 lines of before endophthalmitis in 53% and 75% of eyes, respectively; a loss >2 lines was observed in 31% and 25% of eyes, respectively. CONCLUSIONS: The incidences of infectious and noninfectious endophthalmitis after IVT were low, and the risk did not increase with each successive injection. We found higher rates of noninfectious endophthalmitis with bevacizumab compared with ranibizumab or aflibercept. Three quarters of cases with infectious and two thirds of cases with noninfectious endophthalmitis retained vision within 10 letters of the pre-endophthalmitis level.

TWO YEAR OUTCOMES OF "TREAT AND EXTEND" INTRAVITREAL THERAPY USING AFLIBERCEPT PREFERENTIALLY FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To report 24-month outcomes of a treat and extend (T&E) regimen using aflibercept in eyes with neovascular age-related macular degeneration. METHODS: This was a database observational study that included treatment-naive eyes with neovascular age-related macular degeneration tracked by the Fight Retinal Blindness! outcome registry completing 24 months of sole monotherapy with aflibercept treatment under a T&E regimen between November 1, 2012 and January 31, 2014. Locally weighted scatterplot smoothing curves were used to display visual acuity outcomes. Main outcome measures were change in visual acuity at 24 months and number of injections and visits during the study period. RESULTS: The study population, identified by reviewing the database, consisted of 136 eyes from 123 patients completing 24 months of follow-up on aflibercept. Mean (SD) age was 77.2 (7.0) years, 59% were female. Mean visual acuity increased from 61.4 (∼20/60; SD 17.4) letters at baseline to 67.4 (∼20/45; SD 17.7) letters at 24 months (+6.0 letters [95% confidence interval: 3.3-8.5]; P < 0.001). From baseline to 24 months, the proportion of eyes with visual acuity ≥70 letters (20/40) increased (40%-58%, P < 0.001) and the proportion of eyes with visual acuity ≤35 letters (20/200) remained the same (10%; P = 0.547). Ninety-eight per cent of eyes starting with visual acuity ≥70 letters (20/40) were able to maintain this up to 24 months. From the first to the second year of treatment, the mean number of injections (7.8 [2.1] vs. 5.7 [2.6]; P < 0.001) and visits (8.7 [1.7] vs. 6.5 [2.4]; P < 0.001) decreased for eyes completing 24 months of treatment. When data from 60 eligible eyes that did not complete 2 years follow-up, along with 14 eyes that switched to ranibizumab, were included using last observation carried forward, the mean change in visual acuity from baseline was +5.6 letters (95% confidence interval: 3.3-7.7). CONCLUSION: These data indicate that eyes treated with aflibercept, as a sole therapy, in routine clinical practice with a T&E regimen can achieve good visual outcomes while decreasing the burden of treatments and clinic visits.

Clinical and social characteristics associated with reduced visual acuity at presentation in Australian patients with neovascular age-related macular degeneration: a prospective study from a long-term observational data set. The Fight Retinal Blindness! Project.

IMPORTANCE: Identifying variables that influence presenting visual acuity (VA) in patients with neovascular age-related macular degeneration (nAMD) is important because it is a strong predictor of long-term outcomes. BACKGROUND: To assess the clinical and social characteristics associated with low presenting VA in nAMD patients. DESIGN: The present study is a cross-sectional analysis from a prospective, observational database. PARTICIPANTS: We identified 3242 treatment-naïve patients from 54 Australian practices in the Fight Retinal Blindness! registry. METHODS: Age, gender, ethnicity and VA were recorded at the baseline visit. Socio-economic status was determined using the Australian Bureau of Statistics socio-economic indexes for areas. MAIN OUTCOME MEASURES: Association between clinical and socio-economic characteristics with presenting VA was identified. RESULTS: Poor VA (≤35 letters) in the presenting eye was associated with older age (adjusted odds ratio [AOR]: 1.33 for patients aged ≥80 years vs. <80 years [95% confidence interval, CI: 1.04, 1.71]), treatment at a public practice (AOR: 1.91 for public vs. private practices [95% CI: 1.46, 2.50]) and intermediate (36-69 letters) VA in the fellow eye (AOR: 0.67 [95% CI: 0.47, 0.95] and 0.64 [95% CI: 0.48, 0.85] for poor [≤35 letters] and good [≥70 letters] VA vs. intermediate VA in the fellow eye). Gender, ethnicity and socio-economic status were not independently associated with VA at presentation. CONCLUSIONS AND RELEVANCE: Poor presenting vision is detrimental to the long-term outcomes of nAMD. Poor presentation of nAMD in Australia may not be related to socio-economic circumstances, but due to systems of care. Further research is warranted to determine why patients at public practices present with worse vision compared with private practices in Australia.

Twelve-Month Outcomes of Ranibizumab vs. Aflibercept for Neovascular Age-Related Macular Degeneration: Data from an Observational Study.

PURPOSE: To directly compare visual acuity (VA) outcomes with ranibizumab vs. aflibercept for eyes with neovascular age-related macular degeneration (nAMD) treated in routine clinical practice. DESIGN: Database observational study. PARTICIPANTS: Treatment-naïve eyes with nAMD tracked by the Fight Retinal Blindness outcome registry that commenced anti-vascular endothelial growth factor therapy with ranibizumab or aflibercept between December 1, 2013, and January 31, 2015. Eyes were matched at baseline for VA, age, and choroidal neovascular membrane (CNV) size. METHODS: Locally weighted scatterplot smoothing curves were used to display VA results. Eyes that switched or discontinued treatment were included with their last observation carried forward. MAIN OUTCOME MEASURES: Change in mean VA (number of letters read on a logarithm of the minimum angle of resolution chart); number of injections and visits; proportion of eyes with inactive CNV over 12 months. RESULTS: We identified 394 eyes (197 treated with ranibizumab and 197 with aflibercept) from 372 patients who received treatment from 34 practitioners. Baseline parameters were well matched. The mean (standard deviation [SD]) VA of ranibizumab-treated eyes increased from 58.6 (20.3) letters at baseline to 62.3 (23.9) (+3.7 [95% confidence interval {CI} 1.4-6.1]) letters (P = 0.001), compared with 58.9 (19.2) letters at baseline to 63.1 (21.5) (+4.26 [95% CI 2.0-6.5]) letters (P < 0.001) for eyes receiving aflibercept. The difference in change in crude VA of 0.6 letters between the 2 groups was not statistically significant (P = 0.76), nor was the difference in adjusted mean VA of the 2 groups (P = 0.26). In completers, the mean (SD) numbers of injections (8.1 [2.1] vs. 8.0 [2.3]; P = 0.27) and visits (9.6 [3.0] vs. 9.5 [3.1]; P = 0.15) did not differ between the 2 groups. The adjusted proportion of eyes in which the CNV lesion was graded as inactive during the study was similar between the eyes receiving ranibizumab and aflibercept (74% vs. 77%, respectively; P = 0.63). CONCLUSIONS: Visual acuity outcomes at 12 months did not differ between ranibizumab and aflibercept used for nAMD in this large observational study, nor was a difference in treatment frequency found.

Treatment Patterns and Visual Outcomes during the Maintenance Phase of Treat-and-Extend Therapy for Age-Related Macular Degeneration.

PURPOSE: To present the treatment patterns, disease activity, and visual outcomes of eyes in the maintenance phase of a treat-and-extend regimen for neovascular age-related macular degeneration (nAMD). To compare the maintenance phase behavior of eyes with a shorter induction phase (≤3 injections) with those requiring a longer induction phase (>3 injections). DESIGN: Database observational study. PARTICIPANTS: Eyes with nAMD receiving anti-vascular endothelial growth factor (VEGF) treatment using a treat-and-extend protocol. Persistently active eyes were excluded, as were eyes with <12 months follow-up during the maintenance phase. METHODS: Clinical information from a large prospective international voluntary registry of nAMD was analyzed. The maintenance phase was defined as starting at the first clinician-reported grading of lesion inactivity. MAIN OUTCOME MEASURES: For analyses by eye: treatment interval at first reactivation; time to first reactivation; and visual acuity change during the study period. For analyses by visit: choroidal neovascular membrane activity graded by the treating physician; time since previous injection; and visual acuity loss since previous injection (>0 letters and ≥15 letters). RESULTS: The mean change in visual acuity during the maintenance phase was +1.0 letters at 12 months -0.6 letters at 24 months and -1.5 at 36 months. Median treatment interval increased from 35 days at study entry to 63 days at 12 months and was 60 days at 36 months. 38.5% of eyes remained inactive at all observed visits during the maintenance phase (minimum 1 year follow-up, mean 945 days). The most common treatment interval at first reactivation was 8 weeks. Treatment intervals beyond 12 weeks seemed to be associated with increased risk of disease reactivation, with risk of reactivation reaching 37.4% at treatment intervals of ≥20 weeks. Eyes with a longer induction phase had worse visual outcomes in the maintenance phase, and earlier and more-frequent disease reactivation, although they received injections less frequently. CONCLUSIONS: The detailed behavior of eyes in the maintenance phase of treat-and-extend management for nAMD is presented. Visual acuity was well maintained during the study period. The most common interval at which reactivation first occurred was 8 weeks. Longer duration of induction phase was associated with worse visual acuity outcomes and earlier disease reactivation, perhaps because of undertreatment.

Depressive symptoms in older adults awaiting cataract surgery.

BACKGROUND: To assess the prevalence and predictors of depressive symptoms in a cohort of older adults awaiting cataract surgery and establish threshold vision at which depressive symptoms may emerge. DESIGN: Analysis of cross-sectional baseline data from a longitudinal cohort study of patients aged ≥65 years on Australian public hospital cataract surgery waiting lists. PARTICIPANTS: We included 329 participants enrolled October 2013-August 2015. METHODS: Participants completed assessment of depressive symptoms, visual disability, quality of life, social participation and exercise frequency at least one month prior to cataract surgery. High and low contrast habitual vision was examined and systemic comorbidities noted. MAIN OUTCOME MEASURE: Depressive symptoms prior to first eye cataract surgery. RESULTS: The prevalence of depressive symptoms was 28.6% (94/329). Univariate analysis identified that participants with poorer high contrast vision, reduced quality of life, greater patient-reported visual disability, higher comorbidity score and who were taking more medications were more likely to exhibit signs of depression. Greater patient-reported visual disability (P = 0.02), reduced quality of life (P = 0.003) and a higher comorbidity score (P = 0.02) remained significantly associated with depressive symptoms in the multivariable model. Depressive symptoms emerged at a visual acuity of 6/12. CONCLUSIONS: These findings demonstrate a high prevalence of depressive symptoms in older persons with cataract, emerging at modest levels of vision loss. Efficient referral processes, timely surgical management, and improved screening and coordinated treatment of depressive symptoms during the surgical wait may minimize the negative psychological effects of cataract in this already vulnerable population.

Health Service Use and Mortality of the Elderly Blind.

PURPOSE: To determine whether blindness in older people is associated with increased health service use and mortality. DESIGN: Retrospective matched cohort study from July 1, 1999, through June 30, 2010. PARTICIPANTS: A blind cohort 65 years of age and older from a volunteer blind register and a cohort of age- and gender-matched controls selected randomly from the Western Australian electoral roll. METHODS: Person-level linked hospital, emergency department (ED), mental health, and death records for the blind and control cohorts were used. Generalized estimating equations assuming a negative binomial distribution were used to estimate relative rates of hospital admissions, lengths of stay, and mortality after adjusting for sociodemographic variables and comorbidity. Emergency department and mental health service visits also were quantified. MAIN OUTCOME MEASURES: Relative rates of hospital admissions, lengths of stay, and mortality, as well as crude proportions of ED and mental health service visits. RESULTS: The blind cohort comprised 1726 individuals alongside 1726 matched controls; 39% were men, and the mean age was 83 years. Combined, the cohorts accumulated a total of 34 130 hospital admissions amounting to 201 867 bed-days. After adjusting for the principal reason for hospital admission and comorbidity, the blind cohort was admitted to the hospital 11% (95% confidence interval [CI], 6%-17%) more often than the control cohort. The blind cohort also stayed in the hospital longer than the controls, but this effect varied by age. Blind participants 65 to 69 years of age spent 88% more days (95% CI, 27%-178%) in the hospital compared with age-matched controls, whereas there was no difference in length of stay between the cohorts by 80 years of age (rate ratio, 1.10; 95% CI, 0.97-1.25). A larger proportion of the blind cohort visited a hospital ED and accessed mental health services compared with the control cohort. CONCLUSIONS: Health service use is increased for the elderly blind compared with age-matched controls after accounting for comorbidity. The elderly blind have more hospital admissions, ED visits, and mental health-related visits. The younger elderly blind stay longer in hospital. However, there was no evidence of worse mortality outcomes after adjusting for comorbidity.

Time to initial clinician-reported inactivation of neovascular age-related macular degeneration treated primarily with ranibizumab.

PURPOSE: To characterize in more detail routine treatment patterns of intravitreal ranibizumab for neovascular age-related macular degeneration (nAMD), we analyzed the length of time and the number of injections required until lesions with choroidal neovascularization (CNV) were first graded inactive. DESIGN: Database observational study. PARTICIPANTS: Treatment-naïve eyes receiving predominantly ranibizumab for nAMD in routine clinical practice that were tracked in the Fight Retinal Blindness! observational registry. METHODS: Eyes treated with ranibizumab were followed until CNV was first reported to be "inactive" (i.e., absence of intraretinal fluid and hemorrhages). MAIN OUTCOME MEASURES: The length of time until lesion inactivation occurred and the number of injections required. RESULTS: A total of 1096 eyes (65.8% from women) were included in the study. The median number of weeks until a lesion was graded as inactive after beginning treatment was 15 weeks. One to 3 injections were sufficient to inactivate the lesion in 61.1% of eyes. A mean change in visual acuity of +5.5 logarithm of the minimum angle of resolution letters (95% confidence interval, 4.8-6.3) was found from treatment initiation to the time that eyes were reported as inactive. In eyes with a mean treatment frequency less than every 5.3 weeks, a median of only 3 injections (mean=3.7) were required before lesions with CNV were graded as inactive, but if the mean treatment interval extended beyond 5.3 weeks, the median number of injections required increased sharply to 6 injections (mean, 7 injections). Occult lesions became inactive more slowly than classic lesions. CONCLUSIONS: Most lesions with CNV became inactive with 3 injections of ranibizumab, but a small proportion remained active for more than 12 months. Injection frequency and lesion type were the main factors that predicted the time and number of injections required to render lesions inactive.

Two-year outcomes of "treat and extend" intravitreal therapy for neovascular age-related macular degeneration.

PURPOSE: To report 24-month outcomes of anti-vascular endothelial growth factor (VEGF) therapy for treatment-naïve eyes with neovascular age-related macular degeneration (nAMD) using a treat and extend treatment regimen in routine clinical practice. DESIGN: Database observational study. PARTICIPANTS: We included treatment-naïve eyes receiving predominantly ranibizumab for nAMD in routine clinical practice treated using a treat and extend regimen that were tracked in the Fight Retinal Blindness observational registry. METHODS: A cohort of eyes treated by practitioners using exclusively a treat and extend regimen was extracted from the Fight Retinal Blindness observational registry. MAIN OUTCOME MEASURES: Change in visual acuity (VA) over 2 years and number of injections and visits. RESULTS: Data from 1198 eyes from 1011 patients receiving anti-VEGF therapy using a treat and extend regimen for treatment-naïve nAMD between January 2007 and December 2012 and with 24-month follow-up were included in the analysis. Mean VA increased by +5.3 logarithm of the minimum angle of resolution letters from 56.5 letters (20/80+1) at initial visit to 61.8 (20/60+2) letters at 24 months. Mean VA gains improved and number of injections increased with successive years from +2.7 letters for eyes commencing in 2007 after a mean of 9.7 injections in 2 years, to +7.8 letters for eyes commencing in 2012 after a mean of 14.2 injections over 2 years. The proportion of eyes with VA >20/40 increased from 27% when starting treatment to 45% after 24 months; the proportion with vision of <20/200 remained unchanged (13% initial, 11% at 24 months). Of the included eyes, 90.5% avoided a vision loss of ≥15 letters. There was an overall mean of 13.0 injections over the 24 months, 7.5 injections in the first year and 5.5 in the second year, with a mean of 14.8 clinic visits. CONCLUSIONS: These data indicate that eyes managed in routine clinical practice with a treat and extend regimen can achieve good visual outcomes while decreasing the burden of treatments and clinic visits.

Long-Term Outcomes of Treatment of Neovascular Age-Related Macular Degeneration: Data from an Observational Study.

PURPOSE: To analyze the long-term outcomes of eyes with neovascular age-related macular degeneration (AMD) starting treatment with vascular endothelial growth factor (VEGF) inhibitors at least 5 years earlier. DESIGN: Database observational study. PARTICIPANTS: Treatment-naïve eyes with neovascular AMD tracked by the Fight Retinal Blindness outcome registry that received at least 1 anti-VEGF injection. METHODS: Locally weighted scatterplot smoothing curves were used to display visual acuity (VA) results. MAIN OUTCOME MEASURES: Change in mean VA and number of injections and visits from baseline up to 7 years after initiating treatment. RESULTS: The mean follow-up time of all 1212 identified eyes was 53.5 months, and 549 (45%) continued attending after 60 months. Mean VA improved from 55.1 to 61.4 letters after 6 months and remained above the mean presenting VA for approximately 6 years. After 7 years, mean VA was 2.6 letters lower than baseline for the 131 eyes still being followed; 40% had VA ≥70 (20/40) letters, and 18% had VA ≤35 letters (20/200). Of those with 20/40 VA before treatment, 40% had lost it after 7 years. Geographic atrophy affecting the fovea was thought to be the cause of a ≥10-letter loss after 6.5 years in 37% of a subset of such eyes that were retrospectively analyzed. A median of 6 injections and 9 visits were recorded over the first 12 months, and then 5 treatments and 7 to 9 visits per annum thereafter through 7 years. Treatment was discontinued for 663 eyes (53%) within the first 5 years. Despite initial gains in vision, the mean VA of these eyes had deteriorated to baseline or worse around the time treatment was discontinued. The rate of serious adverse events was low. CONCLUSIONS: Good long-term outcomes of VEGF inhibition for neovascular AMD were found in this study. These results may be better than other reports because more injections were given to our patients, possibly associated with a greater incentive for the physician to treat. Further studies to determine how to maximize the proportion of eyes that retain the initial VA gains of anti-VEGF are warranted.

The Cataract Extraction and Driving Ability Research Study Protocol: characterisation of deficits in driving performance and self-regulation among older drivers with bilateral cataract.

PURPOSE: Cataract is one of the leading causes of visual impairment in Australia. As more older adults are driving, the number of people with cataract on the roads will increase. A greater understanding of the effects of cataract and cataract surgery on driving performance and driver self-regulation is essential to improve road safety. This proposed study will examine the effects of bilateral cataract surgery on driving outcomes including driving performance and driver self-regulation. METHODS: A 3-year prospective study will be undertaken in Western Australia (WA) and New South Wales (NSW). Three hundred participants (n=150 from WA and n=150 from NSW) aged >60 years with bilateral cataract will be assessed at three time points: the month before first-eye cataract surgery, 1-3 months after first-eye cataract surgery and 3 months after second-eye cataract surgery. Driving performance will be assessed using a driving simulator and driver self-regulation patterns measured using in-vehicle driver-monitoring devices. Objective visual measures, quality of life and self-reported driving difficulties will also be collected at the three assessments. CONCLUSIONS: The study results may impact on ophthalmology, optometry and general medical practices in terms of the driving advice provided to patients with bilateral cataract and those undergoing cataract surgery. The information gained from this study will allow these professionals to advise patients about specific driving difficulties they may face at different stages of cataract surgery and appropriate self-regulation practices. The results will be of use to licensing authorities in the assessment of 'fitness to drive'.

Comparison of outcomes from a phase 3 study of age-related macular degeneration with a matched, observational cohort.

OBJECTIVE: To compare outcomes of intravitreal therapy from an observational study cohort with those of participants receiving treatment in the Minimally Classic/Occult Trial of the Anti-VEGF Antibody Ranibizumab (MARINA) for the treatment of neovascular age-related macular degeneration (wet AMD). DESIGN: Database observational study. Participants in the observational cohort were chosen to match demographic features and entry criteria of the treatment group from MARINA. Outcomes over 12 months were compared. PARTICIPANTS: Eight hundred twenty-one anti-vascular endothelial growth factor (anti-VEGF)-naïve eyes treated with ranibizumab with 12 months or more of follow-up were included in the total Fight Retinal Blindness! (FRB-All) cohort, whereas a subset of this cohort of 401 eyes who were matched to the MARINA treatment group were included as the FRB-MARINA cohort. INTERVENTION: Intravitreal ranibizumab therapy of 0.5 mg for wet AMD. METHODS: Visual acuity (VA) in logarithm of the minimum angle of resolution (logMAR) letters and treatments given were recorded continuously and anonymously in an electronic database for 12 months. Locally weighted scatterplot smoothing (LOESS) regression was used to plot change in visual acuity data over the course of 12 months for both the FRB-All cohort and the FRB-MARINA cohort, whereas results from the MARINA trial were taken from the published study report. MAIN OUTCOME MEASURES: Change in VA in logMAR letters over 12 months, treatment, and visit intensity. RESULTS: Mean visual acuity improvement after 12 months in FRB-MARINA (+5.5 letters) was similar to that of the 0.5-mg group from MARINA (+7.2 letters). Improvement in FRB-ALL was slightly less (+4.9 letters). Mean treatment effect compared with the MARINA control group was similar for the MARINA treated group (+17.6 letters) and the FRB-MARINA cohort (+15.9 letters). A mean of 7.3 injections in 12 months was received by the observational cohorts. CONCLUSIONS: Similarity of mean VA improvement in the matched observational cohort with that of the phase 3 clinical trial suggests that these results can be achieved in real-world clinical practice with a modified treatment regimen.

The impact of first- and second-eye cataract surgery on injurious falls that require hospitalisation: a whole-population study.

BACKGROUND: cataract is a leading cause of reversible vision impairment and may increase falls in older adults. OBJECTIVE: to assess the risk of an injury due to a fall among adults aged 60+, 2 years before first-eye cataract surgery, between first-eye surgery and second-eye surgery and 2 years after second-eye surgery. DESIGN: a retrospective cohort study. SETTING: Western Australian Hospital Morbidity Data System and the Western Australian Death Registry. SUBJECTS: there were 28,396 individuals aged 60+ years who underwent bilateral cataract surgery in Western Australia between 2001 and 2008. METHODS: Poisson regression analysis based on generalised estimating equations compared the frequency of falls 2 years before first-eye cataract surgery, between first- and second-eye surgery and 2 years after second-eye cataract surgery after accounting for potential confounders. RESULTS: the risk of an injurious fall that required hospitalisation doubled (risk ratio: 2.14, 95% confidence interval: 1.82 to 2.51) between first- and second-eye cataract surgery compared with the 2 years before first-eye surgery. There was a 34% increase in the number of injurious falls that required hospitalisation in the 2 years after second-eye cataract surgery compared with the 2 years before first-eye surgery (risk ratio: 1.34, 95% confidence interval: 1.16-1.55). CONCLUSIONS: there was an increased risk of injurious falls after first- and second-eye cataract surgery which has implications for the timely provision of second-eye surgery as well as appropriate refractive management between surgeries.

Efficient capture of high-quality data on outcomes of treatment for macular diseases: the fight retinal blindness! Project.

PURPOSE: To describe the development of a web-based high-quality data collection tool to track the outcomes of treatment of macular disease in routine practice. METHODS: Testing of a larger data collection tool established which fields a clinician would reliably fill out. The program, which was developed using freely available software, consists of modules interacting with a core system. The module for neovascular age-related macular degeneration is described here. RESULTS: Data for initial visits can be entered within 30 seconds, 15 seconds for follow-up visits. Fifteen centers from Australia, New Zealand, and Switzerland are currently contributing data. Finalized data from 2,052 eyes of 1,693 participants dating from January 2006 were analyzed. Median (25th and 75th percentiles) visual acuity at the index visit was 55 (41, 68) logarithm of the minimum angle of resolution letters with the following lesion types: minimally classic 17.2%, predominantly classic 24.6%, occult 52.0%, idiopathic polypoidal choroidal vasculopathy 1.2%, and retinal angiomatous proliferation 3.2%. CONCLUSION: This software tool will facilitate the collection of large amounts of data on the routine use of treatments of neovascular age-related macular degeneration. This will allow us to analyze important potentially modifiable variables, such as the effect of different treatment patterns on visual outcomes, and to evaluate new treatments as they are introduced into practice.

Falls in Older people with Cataract, a longitudinal evalUation of impact and riSk: the FOCUS study protocol.

BACKGROUND: Falls result in >$1 billion in treatment, disability, lost output and mortality each year in Australia and people with cataract are at increased risk. Previous research is inconclusive; one large Australian study using linked hospital data found no protective effect of cataract surgery. We aim to examine the impact of cataract-related vision impairment on falls risk and the additional effects of delays in access to surgery, refractive management (type of spectacles and changes to spectacle prescription) and the resulting level of function, particularly binocular function which can impact balance. METHOD/DESIGN: A prospective, 24-month cohort study is planned involving over 700 patients aged 70 years or older with bilateral cataract presenting for surgery at five public hospital eye clinics in Sydney, Melbourne and Perth, Australia. The primary outcomes will be self-reported falls and falls requiring medical care, assessed objectively using administrative data sets. Secondary outcomes include community participation, quality of life, mood and depressive symptoms. McNemar's test will be used to evaluate differences in falls rate before, after first eye and after second eye cataract surgery. Generalised Estimating Equations linear regression analysis will be undertaken to examine factors associated with falls risk and the secondary outcomes. DISCUSSION: With limited resources to further shorten public waiting lists, there is a need to better understand an individuals' risk of fall injury or other negative consequences while waiting for surgery. The findings of this project will inform the development of strategies to reduce falls risk in the many older people with cataract.

Myocardial infarction after intravitreal vascular endothelial growth factor inhibitors: a whole population study.

PURPOSE: To determine the risk of thromboembolic and gastrointestinal bleeding events in the 12 months after injections of bevacizumab or ranibizumab compared with photodynamic therapy and a nontreated community sample. METHODS: Hospital and death records were examined for 1,267 patients treated with vascular endothelial growth factor inhibitor and 399 patients treated with photodynamic therapy attending Western Australian eye clinics from 2002 to 2008, and 1,763 community controls, aged ≥50 years. Hospital records from 1995 to 2009 were analyzed for history of myocardial infarction (MI), stroke, and gastrointestinal bleeding before treatment. Records were searched for evidence of these events in the 12 months after treatment. RESULTS: The 12-month MI rate was higher for vascular endothelial growth factor inhibitor patients than photodynamic therapy patients and the community group (1.9/100 vs. 0.8 and 0.7, respectively). No differences were observed between patients treated with bevacizumab and ranibizumab. The adjusted MI rate was 2.3 times greater than the community group (95% confidence interval, 1.2-4.5) and photodynamic therapy rate (95% confidence interval, 0.7-7.7). The 12-month MI risk did not increase with the number of injections administered (hazard ratio, 0.9; 95% confidence interval, 0.5-1.5). Stroke and gastrointestinal bleeding did not differ between any exposure groups. CONCLUSION: Although all the adverse events examined were rare, patients treated with vascular endothelial growth factor inhibitors were significantly more likely to experience fatal or nonfatal MI than the community group. This increased risk may be related to the underlying age-related macular degeneration or vascular endothelial growth factor inhibitor use itself.

Driver self-regulation and depressive symptoms in cataract patients awaiting surgery: a cross-sectional study.

BACKGROUND: Cataract is an extremely common visual condition of ageing. Evidence suggests that visual impairment influences driving patterns and self-regulatory behavior among older drivers. However, little is known about the psychological effects of driver self-regulation among older drivers. Therefore, this study aimed to describe driver self-regulation practices among older bilateral cataract patients and to determine the association between self-regulation and depressive symptoms. METHODS: Ninety-nine older drivers with bilateral cataract were assessed the week before first eye cataract surgery. Driver self-regulation was measured via the Driving Habits Questionnaire. Depressive symptoms were assessed using the 20-item Center for Epidemiological Studies Depression Scale. Visual, demographic and cognitive data were also collected. Differences between self-regulators and non self-regulators were described and linear regression modeling used to determine the association between driver self-regulation and depressive symptoms score. RESULTS: Among cataract patients, 48% reported self-regulating their driving to avoid at least one challenging situation. The situations most commonly avoided were driving at night (40%), on the freeway (12%), in the rain (9%) and parallel parking (8%). Self-regulators had significantly poorer contrast sensitivity in their worse eye than non self-regulators (p = 0.027). Driver self-regulation was significantly associated with increased depressive symptoms after controlling for potential confounding factors (p = 0.002). CONCLUSIONS: Driver self-regulation was associated with increased depressive symptoms among cataract patients. Further research should investigate this association among the general older population. Self-regulation programs aimed at older drivers may need to incorporate mental health elements to counteract unintended psychological effects.

Hospitalization rates of children who are blind.

BACKGROUND: To evaluate the impact of blindness on hospitalization rates of children. DESIGN: Matched cohort study. PARTICIPANTS: Children confirmed as legally blind (2003-2009), age- and gender-matched to control cohort of normally sighted children from the state register of births. METHODS: The rates and reasons for admission to hospital were compared using hospital morbidity records. The association of blindness with rates of admission and length of stay in hospital, 2003-2010, were estimated using multivariate negative binomial regression models. MAIN OUTCOME MEASURES: Descriptive statistics, incident rate ratios, and predicted means for hospital separations and length of stay. RESULTS: Fifty-nine blind and 59 control children had a combined total of 107 separations accounting for 237 bed days in hospital after the index date of legal blindness. The median age at the index date was 8 years. Over 90% of separations and 92% of bed days were incurred by 22 blind children. Blind children had four (95% confidence interval 1.9-9.3) times more hospital separations and stayed in hospital six (95% confidence interval 1.9-17.5) times longer than the control cohort children. There were more than 40 times as many comorbidities recorded by the blind children (n = 201) compared with the control children (n = 5). A third of the blind children were hospitalized for respiratory conditions. CONCLUSIONS: Children who are born or become blind in childhood have more and longer periods in hospital than sighted children likely because of complex comorbid health problems. There was a disproportionate incidence of comorbid respiratory diseases in the blind children.

Vision, quality of life and depressive symptoms after first eye cataract surgery.

BACKGROUND: Cataract affects not only vision, but also performance of everyday tasks, participation in social activities, quality of life and possibly depression. Depression is a major health issue for older adults. It is estimated that 6%-20% of community-dwelling older Australians experience depression. The aim of this study was to investigate changes in vision-related quality of life and depressive symptoms after first eye cataract surgery and to determine which visual measures affect the change in these outcomes. METHODS: In 2009 and 2010, 99 participants with bilateral cataract were recruited. Visual measures including visual acuity, contrast sensitivity and stereopsis were assessed 1 week before and 12 weeks after first eye cataract surgery. Vision-related quality of life was measured using the 25-item National Eye Institute Visual Function Questionnaire. Depressive symptoms were assessed by the 20-item Center for Epidemiological Studies Depression Scale. Separate regression analyses were undertaken to determine the association between visual measures and changes in vision-related quality of life and depressive symptoms after first eye cataract surgery. RESULTS: Overall, vision-related quality of life improved after first eye cataract surgery. There was a small, non-clinically significant improvement in depressive symptoms after surgery. Improvement in vision-related quality of life after first eye cataract surgery was associated with improved contrast sensitivity in the operated eye (P < 0.001), whereas improvement in depressive symptoms after surgery was associated with improved stereopsis (P = 0.032). CONCLUSIONS: Contrast sensitivity and stereopsis, but not visual acuity, were significant factors affecting improvement in vision-related quality of life or depressive symptoms after first eye cataract surgery.