Identifying the content for an item bank and computerized adaptive testing system to measure the impact of age-related macular degeneration on health-related quality of life.

PURPOSE: We are developing an age-related macular degeneration (AMD) health-related quality of life (HRQoL) item bank, applicable to Western and Asian populations. We report primarily on content generation and refinement, but also compare the HRQoL issues reported in our study with Western studies and current AMD-HRQoL questionnaires. METHODS: In this cross-sectional, qualitative study of AMD patients attending the Singapore National Eye Centre (May-December 2019), items/domains were generated from: (1) AMD-specific questionnaires; (2) published articles; (3) focus groups/semi-structured interviews with AMD patients (n = 27); and (4) written feedback from retinal experts. Following thematic analysis, items were systematically refined to a minimally representative set and pre-tested using cognitive interviews with 16 AMD patients. RESULTS: Of the 27 patients (mean ± standard deviation age 67.9 ± 7.0; 59.2% male), 18 (66.7%), two (7.4%), and seven (25.9%) had no, early-intermediate, and late/advanced AMD (better eye), respectively. Whilst some HRQoL issues, e.g. activity limitation, mobility, lighting, and concerns were similarly reported by Western patients and covered by other questionnaires, others like anxiety about intravitreal injections, work tasks, and financial dependency were novel. Overall, 462 items within seven independent HRQoL domains were identified: Activity limitation, Lighting, Mobility, Emotional, Concerns, AMD management, and Work. Following item refinement, items were reduced to 219, with 31 items undergoing amendment. CONCLUSION: Our 7-domain, 219-item AMD-specific HRQoL instrument will undergo psychometric testing and calibration for computerized adaptive testing. The future instrument will enable users to precisely, rapidly, and comprehensively quantify the HRQoL impact of AMD and associated treatments, with item coverage relevant across several populations.

COMPARISON OF OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHIC CHANGES AFTER ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY ALONE OR IN COMBINATION WITH PHOTODYNAMIC THERAPY IN POLYPOIDAL CHOROIDAL VASCULOPATHY.

PURPOSE: To compare changes in optical coherence tomography angiography in eyes with polypoidal choroidal vasculopathy after treatment with anti-vascular endothelial growth factor monotherapy or combined with photodynamic therapy. METHODS: This is a longitudinal case-controlled study. The authors performed optical coherence tomography angiography at baseline and Month 3 in patients with treatment-naive polypoidal choroidal vasculopathy undergoing monotherapy (n = 10) or combination therapy (n = 13). We analyzed flow signal within the outer retina and choriocapillaris using automated segmentation. The authors analyzed the presence of pachyvessels using a 10.4-µm segment through Haller layer. The changes in each layer were compared between treatments. RESULTS: At Month 3, both groups showed similar improvement in best-corrected visual acuity and central retinal thickness. However, flow signal within the polypoidal choroidal vasculopathy complex was decreased in more eyes after combination therapy than after monotherapy (84.6% vs. 40.0%, P = 0.04). Patchy reduction in flow signal within the choriocapillaris layer was noted in 15.4% and 10.0% after combination therapy and monotherapy, respectively (P = 0.61). Significant reduction in pachyvessel caliber was seen only after combination therapy but not after monotherapy (75.0% vs. 0.0%, P = 0.01). CONCLUSION: Longitudinal optical coherence tomography angiography demonstrates more significant reduction in lesion flow and pachyvessels in the short term after combination therapy than after monotherapy, although visual and structural OCT showed similar improvement.

SCLERAL BUCKLING VERSUS VITRECTOMY IN THE MANAGEMENT OF MACULA-OFF PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT: A COMPARISON OF VISUAL OUTCOMES.

PURPOSE: To compare visual outcomes between pars plana vitrectomy (PPV) with or without scleral buckling (SB) and SB alone in the management of uncomplicated macula-off primary rhegmatogenous retinal detachment. METHODS: Case-control study of 723 patients with uncomplicated macula-off primary rhegmatogenous retinal detachment seen at the Singapore National Eye Centre from 2005 to 2011. The primary outcome measure was the proportion of eyes achieving functional success, defined as logMAR best-corrected visual acuity of ≤0.3 logMAR at 6 months postoperatively. Multivariable logistic regression analysis was performed adjusting for the following preoperative covariates: age, gender, race, lens status, number of tears found, presence of proliferative vitreoretinopathy, operative procedure, logMAR best-corrected visual acuity, and duration of symptoms. RESULTS: Three hundred and eight eyes underwent SB alone, and 415 eyes underwent PPV ± SB. In the SB group, 133 eyes (43.2%) achieved functional success compared with 116 eyes (28.0%) in the PPV ± SB group. This difference was statistically significant on both univariate (P < 0.001) and multivariable analyses (OR: 1.51, 95% CI: 1.03-2.21, P = 0.03). CONCLUSION: Scleral buckling alone may achieve visual outcomes that are at least comparable with PPV ± SB in the management of macula-off primary rhegmatogenous retinal detachment.

Extracapsular cataract extraction training: junior ophthalmology residents' self-reported satisfaction level with their proficiency and initial learning barrier.

PURPOSE: To investigate residents' self-reported satisfaction level with their proficiency in extracapsular cataract extraction (ECCE) surgery and the initial barriers to learning the procedure. METHODS: This is a single-centre prospective descriptive case series involving eight first-year ophthalmology residents in Singapore National Eye Center. We recorded the demographics, frequency of review by the residents of their own surgical videos and their satisfaction level with their proficiency at each of the ECCE steps using a 5-point Likert scale. All ECCE surgical videos between October 2013 and May 2014 were collected and analysed for the overall time taken for the surgery and the time taken to perform the individual steps of the procedure. RESULTS: The mean age of the residents was 27.6 ± 1.5 years and 62.5% (5/8) were women. More than half (62.5%, 5/8) reviewed their own surgical videos while 37.5% (3/8) discussed the surgical videos with their peers or supervisors. Of the ECCE steps, the residents were most dissatisfied with their proficiency in performing irrigation and aspiration (87.5%, 7/8), followed by suturing (62.5%, 5/8), intraocular lens insertion (62.5%, 5/8) and tin can capsulotomy (62.5%, 5/8). The average time taken for each ECCE case was 55.0 ± 12.2 min and, of all the steps, most time was spent on suturing (20.5 ± 6.8 min), followed by irrigation and aspiration (5.5 ± 3.6 min) and tin can capsulotomy (3.3 ± 1.8 min). CONCLUSIONS: The first-year ophthalmology residents were most dissatisfied with their proficiency in irrigation/aspiration, suturing and tin can capsulotomy. More training needs to be directed to these areas during teaching sessions in the operating room, wet laboratory or cataract simulation training sessions.

Trends and factors related to outcomes for primary rhegmatogenous retinal detachment surgery in a large asian tertiary eye center.

PURPOSE: To describe trends and outcomes of vitreoretinal surgery for primary rhegmatogenous retinal detachment in a large Asian tertiary eye center. METHODS: Retrospective review of 1,530 eyes with primary retinal detachment between 2005 and 2011 managed at the Singapore National Eye Center by one of the following: scleral buckling (SB), pars plana vitrectomy (PPV), and combined SB and PPV (SB + PPV). Anatomical and functional outcomes were assessed. RESULTS: There was a trend toward PPV and PPV + SB as the primary reattachment procedure from 2005 to 2011. The primary anatomical success rate for PPV (78.6%) was worse than that for SB (88.8%) or SB + PPV (89.0%, P = 0.000). Final anatomical success rates were similar for all 3 procedures: SB 97.7%, PPV 95.2%, and SB + PPV 96.4%. Better functional success was achieved in the SB group (86.1%) than both the PPV (72.5%) and SB + PPV groups (77.5%, P = 0.000), partly attributable to the less complex nature of retinal detachments in the SB group. Older age and proliferative vitreoretinopathy were related to the poor functional outcomes in both phakic and pseudophakic eyes. CONCLUSION: There was an increasing trend toward PPV and PPV + SB as the primary retinal reattachment surgery from 2005 through to 2011. High rates of anatomical and functional outcomes were achieved with SB, PPV, and SB + PPV, proliferative vitreoretinopathy and older age were negatively correlated with the functional success in both phakic and pseudophakic eyes.

Trends in age-related macular degeneration management in Singapore.

PURPOSE: To describe the trends and patterns of anti-vascular endothelial growth factor (anti-VEGF) therapy and photodynamic therapy (PDT) use for age-related macular degeneration (AMD) in the National Eye Centre in Singapore over a 4-year period. METHODS: Data on the total number of intravitreal anti-VEGF injections and PDT treatment over a 4-year period at the Singapore National Eye Centre were obtained from centralized electronic records. Patients aged 40 years and older treated for AMD were included. Data retrieved included the annual treatment load in terms of number of new patients and total treatment episodes, and treatment burden for patients was studied in terms of number of injections per year and cumulative injection numbers over 3 years. Potential influence on retreatment by choice of drug, use of adjunct PDT, and diagnosis of polypoidal choroidal vasculopathy were further analyzed. RESULTS: From 2009 to 2012, a total of 6157 injections were performed on 1380 unique individual patients. The total number of injections performed per calendar year increased from 962 in 2009 to 2278 in 2012. The number of unique incident cases increased from 287 in 2009 to 446 in 2012. The mean number of injections over the first year increased from 2.62 in 2009 to 3.19 in 2012 (p < 0.001). Choice of anti-VEGF therapy did not significantly alter the cumulative injections required. Patients diagnosed as having polypoidal choroidal vasculopathy had similar injection episodes (p = 0.178), whereas choice of anti-VEGF and adjunct PDT had no effect on the overall treatment. CONCLUSIONS: Anti-VEGF treatment of AMD continues to increase substantially year on year in the past few years, in alignment with experience from other countries. However, the cumulative number of injections per patient remains low, and many patients discontinue treatment within the first year. These data demonstrate that undertreatment remains a significant concern in clinical settings.

The Ophthalmology Surgical Competency Assessment Rubric for Intravitreal Injections (ICO-OSCAR:IVI).

(1) Background: Intravitreal injections (IVIs) are the most commonly performed intraocular procedure worldwide. Ensuring correct learning is essential to avoid complications. Our purpose was to develop an internationally valid tool to assess skill in performing IVIs. (2) Methods: A panel of six content experts designed a rubric for assessing the IVI procedure by using a modified Dreyfus scale of skill acquisition, dividing it into steps and providing objective behavioral descriptors for each level of skill in each category, following the International Council of Ophthalmology (ICO) guidance. The rubric draft was then critically reviewed by 12 international content experts, and their constructive comments were considered for the final rubric. (3) Results: The Ophthalmology Surgical Competency Assessment Rubric for IVI (ICO-OSCAR:IVI) is the proposed tool for assessing healthcare professionals training to perform IVI. (4) Conclusions: The ICO-OSCAR:IVI is the result of the consensus of an international expert panel. The methodology used for its development provides this rubric with face and content validity. It can be used globally to assess healthcare professionals training to perform IVI, as well as the impact of different teaching methods on performance. Further studies are required to establish intra- and inter-rater reliability, as well as the predictive validity of this tool.

Retinal photograph-based deep learning algorithms for myopia and a blockchain platform to facilitate artificial intelligence medical research: a retrospective multicohort study.

BACKGROUND: By 2050, almost 5 billion people globally are projected to have myopia, of whom 20% are likely to have high myopia with clinically significant risk of sight-threatening complications such as myopic macular degeneration. These are diagnoses that typically require specialist assessment or measurement with multiple unconnected pieces of equipment. Artificial intelligence (AI) approaches might be effective for risk stratification and to identify individuals at highest risk of visual loss. However, unresolved challenges for AI medical studies remain, including paucity of transparency, auditability, and traceability. METHODS: In this retrospective multicohort study, we developed and tested retinal photograph-based deep learning algorithms for detection of myopic macular degeneration and high myopia, using a total of 226 686 retinal images. First we trained and internally validated the algorithms on datasets from Singapore, and then externally tested them on datasets from China, Taiwan, India, Russia, and the UK. We also compared the performance of the deep learning algorithms against six human experts in the grading of a randomly selected dataset of 400 images from the external datasets. As proof of concept, we used a blockchain-based AI platform to demonstrate the real-world application of secure data transfer, model transfer, and model testing across three sites in Singapore and China. FINDINGS: The deep learning algorithms showed robust diagnostic performance with areas under the receiver operating characteristic curves [AUC] of 0·969 (95% CI 0·959-0·977) or higher for myopic macular degeneration and 0·913 (0·906-0·920) or higher for high myopia across the external testing datasets with available data. In the randomly selected dataset, the deep learning algorithms outperformed all six expert graders in detection of each condition (AUC of 0·978 [0·957-0·994] for myopic macular degeneration and 0·973 [0·941-0·995] for high myopia). We also successfully used blockchain technology for data transfer, model transfer, and model testing between sites and across two countries. INTERPRETATION: Deep learning algorithms can be effective tools for risk stratification and screening of myopic macular degeneration and high myopia among the large global population with myopia. The blockchain platform developed here could potentially serve as a trusted platform for performance testing of future AI models in medicine. FUNDING: None.

Intravitreal Injection with a Conjunctival Injection Device: A Single-Center Experience.

Purpose: To evaluate the clinical performance of the intravitreal injection assistant device (InVitria) compared with the conventional freehand technique for delivering intravitreal injections. Methods: Seventy patients were randomized to receive intravitreal injections via the conventional freehand technique while 70 received injections using the InVitria. Half of all procedures in each group were performed by junior surgeons, while the rest were performed by senior surgeons. Results: Mean injections times were 90.0 ± 23.3 seconds and 64.9 ± 26.8 seconds for conventional versus InVitria (P < 0.001). Mean injection times with the conventional technique were 85.5 ± 23.0 seconds vs. 94.2 ± 23.0 seconds for senior versus junior surgeons (P = 0.120). Mean injection times with the InVitria were 56.1 ± 26.1 seconds vs. 66.3 ± 26.9 seconds (P = 0.211) for senior versus junior surgeons. There were no significant differences in pain scores regardless of technique (conventional versus In Vitria: 2.03 ± 1.73 vs. 2.13 ± 2.20, P = 0.770). Conclusions: In our experience, the InVitria is a comparable alternative to the conventional freehand technique of delivering intravitreal injections, with the potential for faster injection times and without compromising on patient comfort. Translational Relevance: The study provides evidence to suggest that the InVitria may be deployed effectively in clinical practice.

Design, implementation, and evaluation of a nurse-led intravitreal injection programme for retinal diseases in Singapore.

BACKGROUND: To describe the design, implementation, and evaluation of a nurse-led intravitreal injection (NL-IVT) programme in a Singapore tertiary eye hospital. METHODS: Patients requiring anti-vascular endothelial growth factor (VEGF) IVT were recruited. Implementation and evaluation were done in the Singapore National Eye Centre, a tertiary centre. To assess safety, nurse injectors recorded details of procedures performed and complications for an 8-month period from February 2019. To evaluate patient experience, we used a modified patient questionnaire and recorded both patients' waiting time and IVT procedure duration. A retrospective audit of IVTs before and after the introduction of NL-IVT was performed from January 2017 to September 2019. Cost difference between NL-IVT and standard doctor-led (DL) IVT was evaluated. RESULTS: A total of 8599 NL-IVTs were performed. No cases of severe complication were detected in the follow-up. A total of 135 patients who received NL-IVT and DL-IVT were surveyed. General satisfaction, interpersonal manner, financial aspect, time spent with injector, and staff competence were higher in NL-IVTs than in DL-IVTs (p < 0.05). There were no differences in terms of technical quality and communication. For 934 patients, waiting time was significantly shorter in NL-IVT (3.6 ± 10.3 min) compared with DL-IVTs (35.3 ± 32.3 min); on average, 19.7 min were saved through NL-IVT (p < 0.01). The cost difference per IVT between NL-IVT and DL-IVT is estimated at 286 SGD (163 GBP). CONCLUSION: With a well-designed training programme, NL-IVT is a safe, acceptable, and cost savings procedure. With increasing demand for IVT, NL-IVT provides an alternative model of care for healthcare systems globally.

Correction: Design, implementation, and evaluation of a nurse-led intravitreal injection programme for retinal diseases in Singapore.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Choroidal Remodeling in Age-related Macular Degeneration and Polypoidal Choroidal Vasculopathy: A 12-month Prospective Study.

Choroid thinning occurs in age-related macular degeneration (AMD). However, it remains unclear whether the reduction is due to reduction in choroidal vessels or shrinkage of choroidal stroma, or both. The purpose of this study was to evaluate the changes of the choroidal vascular and stromal area in 118 patients with typical AMD (t-AMD) and polypoidal choroidal vasculopathy (PCV) over a 12-month period. We used spectral-domain optical coherence tomography (SD-OCT) with enhanced depth imaging (EDI) mode to measure the subfoveal choroidal thickness (CT), central retinal thickness (CRT) and choroidal vascularity index (CVI - ratio of luminal area to total choroidal area). At baseline, PCV eyes had higher CRT (471.6 µm vs 439.1 µm, p = 0.02), but comparable subfoveal CT and CVI, compared to t-AMD. Eyes with high CVI at baseline showed marked reduction in stromal area compared with eyes with average or low CVI. Over 12 months, CRT and subfoveal CT significantly decreased (p < 0.001) in both subtypes. Eyes with high baseline CVI showed significant CVI reduction from baseline to month 12 (p < 0.001), whereas eyes with average to low baseline CVI showed increase in CVI. These differences in choroidal vascularity may reflect different predominant pathogenic processes and remodeling in AMD eyes with varying spectrum.

Ophthalmology simulation for undergraduate and postgraduate clinical education.

This is a review education paper on the current ophthalmology simulators utilized worldwide for undergraduate and postgraduate training. At present, various simulators such as the EYE Exam Simulator (Kyoto Kagaku Co. Ltd., Kyoto, Japan), Eyesi direct ophthalmoscope simulator (VRmagic, GmbH, Mannheim, Germany), Eyesi indirect ophthalmoscope simulator (VRmagic, GmbH, Mannheim, Germany) and Eyesi cataract simulators (VRmagic, GmbH, Mannheim, Germany). These simulators are thought to be able to reduce the initial learning curve for the ophthalmology training but further research will need to be conducted to assess the effectiveness of the simulation-assisted Ophthalmology training. Future research will be of great value to assess the medical students and residents' responses and performance regarding the usefulness of the individual eye simulator.

Choroidal Thickness Changes in Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy: A 12-Month Prospective Study.

PURPOSE: To describe 12-month changes in choroidal thickness after anti-vascular endothelial growth factor (anti-VEGF) therapy for typical age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV). DESIGN: Prospective, consecutive, noninterventional, longitudinal case series. METHODS: This study included patients with typical AMD and PCV who received anti-VEGF therapy over a 12-month period. We used spectral-domain optical coherence tomography with enhanced depth imaging mode to measure choroidal thickness. RESULTS: Of the 163 patients, 77 had typical AMD and 86 had PCV. Patients with PCV were younger (67.6 vs 72.5 years, P < .01) and received fewer anti-VEGF injections (3.9 vs 5.6, P = .02) than patients with typical AMD. Baseline subfoveal choroidal thickness was not significantly different between PCV and typical AMD eyes, and was thicker in the study eye compared to fellow eye in the typical AMD group (223.1 vs 208.8 µm, P < .01). Subfoveal choroidal thickness decreased significantly in both typical AMD (213.7 µm to 190.3 µm, P < .001) and PCV (240.8 µm to 213.4 µm, P < .01) eyes, but no significant change was noted in fellow unaffected eyes. Reduction in choroidal thickness was associated with elevated C-reactive protein (odds ratio [OR]: 1.4, P = .04) and smoking (OR: 7.6, P = .03) at baseline, but not with age, refractive error, diagnosis of typical AMD or PCV, number or type of anti-VEGF injections, PDT therapy, or baseline choroidal thickness. CONCLUSIONS: A significant reduction in subfoveal choroidal thickness was noted after anti-VEGF therapy in typical AMD and PCV. Choroidal thickness changes were similar despite differences in number of anti-VEGF treatment.