Factors related to training time and achieving proficiency with visual-assistive mobile applications in visually impaired older adults.

SIGNIFICANCE: A majority of visually impaired older adults were able to learn to proficiently use visual-assistive iPhone applications (apps) following a median 1 hour and/or multiple training sessions, which should be considered when planning vision rehabilitation service delivery, including the option for remote telerehabilitation for those who prefer that modality. PURPOSE: Older adults with low vision are increasingly using technology to improve their visual functioning. We examined whether age-related comorbidities were potential barriers to success in learning to use visual-assistive apps on a smartphone. METHODS: A clinical trial assessed visual-assistive apps in 116 older adults aged 55+ years (mean [standard deviation], 72 [10] years). Subjects were randomized to use an app (SuperVision+, Seeing AI, or Aira) preloaded to a loaner iPhone and completed one-on-one training. App proficiency was measured by the participant's ability to use the iPhone/app without cueing at the end of training sessions. Training time was recorded for the initial session and totaled after subsequent sessions. Multiple regression models explored significant factors associated with training time and proficiency. RESULTS: Median initial and total training times were 45 and 60 minutes, respectively. Increased initial and total training times were both significantly related to increased age (p<0.001), legal blindness (p<0.007), Seeing AI versus SuperVision+ app (p<0.03), and participants from New England versus California (p<0.001). Most (71%) achieved proficiency after the initial training session; those odds were significantly greater among younger participants (p=0.04), those who opted for telerehabilitation (p=0.03), those who had higher cognitive scores (p=0.04), or those who were from New England (p=0.04). The majority (90%) was ultimately proficient with the app; those odds were significantly greater among participants who already had an optical magnifier (p=0.008), but were unrelated to other factors including study site. CONCLUSIONS: Following multiple, extensive training sessions, age, mild cognitive loss, or level of visual impairment did not preclude gaining proficiency with visual-assistive apps by visually impaired seniors, but those factors were associated with longer training times. Telerehabilitation can be a viable option to provide app training remotely for visually impaired seniors who choose that modality.

Outcomes of Telerehabilitation Versus In-Office Training With Magnification Devices for Low Vision: A Randomized Controlled Trial.

Purpose: An evidence basis is lacking but needed to compare reading ability outcomes after magnification device training remotely via telerehabilitation versus in office. Methods: A multicenter randomized controlled trial at academic centers and vision rehabilitation private practices randomized 61 visually impaired adults to telerehabilitation or in-office training 1 to 4 months after dispensing new portable electronic, hand-held, or stand optical magnifiers. Telerehabilitation included loaner equipment for Zoom videoconferencing with remote control access software. Using a multilevel regression model, changes in Activity Inventory responses using Rasch analysis estimated reading ability in dimensionless log odds units (logits) (0.14-logit change corresponds with ability change expected from a one-line change in visual acuity). Results: Across 47 participants who completed the trial, reading ability with new magnifiers improved significantly by 0.61 logits on average (95% confidence interval [CI], 0.36-0.86; P < 0.001) from baseline to 1 month, and by an additional 0.44 logits on average (95% CI, 0.19-0.69; P < 0.001) from 1 to 4months (i.e., after magnifier training), with very similar significant findings for both telerehabilitation (n = 29; mean improvement = 0.44 logits; 95% CI, 0.08-0.80; P = 0.018) and in-office training (n = 18; mean improvement = 0.43 logits; 95% CI, 0.15-0.71; P = .003), and no significant difference between randomized groups across both follow-ups (95% CI, -0.43 to 0.61; P = .73). Vision, demographics, and health factors were nonsignificantly related to reading ability changes from 1 to 4 months. Conclusions: Reading ability improved after the provision of newly dispensed magnifiers, with further improvements following additional magnifier training via either telerehabilitation or in-office usual care. Translational Relevance: These findings provide support for the use of telerehabilitation to enhance reading ability with newly prescribed magnifiers as an alternative modality of care delivery.

Retinal mid-peripheral capillary free zones are enlarged in cognitively unimpaired older adults at high risk for Alzheimer's disease.

BACKGROUND: Compared to standard neuro-diagnostic techniques, retinal biomarkers provide a probable low-cost and non-invasive alternative for early Alzheimer's disease (AD) risk screening. We have previously quantified the periarteriole and perivenule capillary free zones (mid-peripheral CFZs) in cognitively unimpaired (CU) young and older adults as novel metrics of retinal tissue oxygenation. There is a breakdown of the inner retinal blood barrier, pericyte loss, and capillary non-perfusion or dropout in AD leading to potential enlargement of the mid-peripheral CFZs. We hypothesized the mid-peripheral CFZs will be enlarged in CU older adults at high risk for AD compared to low-risk individuals. METHODS: 20 × 20° optical coherence tomography angiography images consisting of 512 b-scans, 512 A-scans per b-scan, 12-µm spacing between b-scans, and 5 frames averaged per each b-scan location of the central fovea and of paired major arterioles and venules with their surrounding capillaries inferior to the fovea of 57 eyes of 37 CU low-risk (mean age: 66 years) and 50 eyes of 38 CU high-risk older adults (mean age: 64 years; p = 0.24) were involved in this study. High-risk participants were defined as having at least one APOE e4 allele and a positive first-degree family history of AD while low-risk participants had neither of the two criteria. All participants had Montreal Cognitive Assessment scores ≥ 26. The mid-peripheral CFZs were computed in MATLAB and compared between the two groups. RESULTS: The periarteriole CFZ of the high-risk group (75.8 ± 9.19 µm) was significantly larger than that of the low-risk group (71.3 ± 7.07 µm), p = 0.005, Cohen's d = 0.55. The perivenule CFZ of the high-risk group (60.4 ± 8.55 µm) was also significantly larger than that of the low-risk group (57.3 ± 6.40 µm), p = 0.034, Cohen's d = 0.42. There were no significant differences in foveal avascular zone (FAZ) size, FAZ effective diameter, and vessel density between the two groups, all p > 0.05. CONCLUSIONS: Our results show larger mid-peripheral CFZs in CU older adults at high risk for AD, with the potential for the periarteriole CFZ to serve as a novel retinal vascular biomarker for early AD risk detection.

Value of Handheld Optical Illuminated Magnifiers for Sustained Silent Reading by Visually Impaired Adults.

SIGNIFICANCE: Vision rehabilitation providers tend to recommend handheld, illuminated optical magnifiers for short-duration spot reading tasks, but this study indicates that they are also a viable option to improve sustained, continuous text reading (e.g., books or magazines), especially for visually impaired adults who read slowly with only spectacle-based near correction. PURPOSE: The utility of handheld optical magnifiers for sustained silent reading tasks involving normal-sized continuous text could be a valuable indication that is not recognized by vision rehabilitation providers and patients. METHODS: Handheld, illuminated optical magnifiers were dispensed to 29 visually impaired adults who completed the sustained silent reading test by phone at baseline without the new magnifier and 1 month after using the magnifier. Reading speed in words per minute (wpm) was calculated from the time to read each page and then averaged across up to 10 pages or determined for the fastest read page (maximum). RESULTS: From baseline without the magnifier to 1 month with the magnifier, there was a significant improvement in mean reading speed by 14 wpm (95% confidence interval [CI], 2.6 to 24; P = .02) and for maximum reading speed by 18 wpm (95% CI, 5.4 to 30; P = .005) on average across participants. Participants who had slower baseline reading speeds without the magnifier demonstrated significantly greater improvements in mean and maximum reading speeds on average with the magnifier (95% CI, 8 to 32 [ P = .003]; 95% CI, 4 to 36 [ P = .02]). A significantly greater number of pages were read with the new magnifier than without it (Wilcoxon z = -2.5; P = .01). A significantly greater number of pages were read with the magnifier by participants who read fewer pages at baseline (95% CI, 0.57 to 5.6; P = .02) or had greater improvements in mean reading speed (95% CI, 0.57 to 5.6; P = .007). CONCLUSIONS: Many visually impaired adults read more quickly and/or read a greater number of pages after using a new magnifier for a month than compared to without it. The largest gains occurred among those with more difficulty at baseline, indicating the potential to improve reading rates with magnifiers for those with greater deficits.

New insights into visually impaired patients' preferred reading illumination and home-based reading speed with new task-lighting.

INTRODUCTION: When optimal lighting is applied to hard-copy materials for visually impaired individuals, laboratory-based reading performance can improve significantly. However, it is not known whether their lighting preferences are related to ocular factors or if laboratory-based reading improvements will translate to home-based environments. METHODS: Preferences for brightness (lux) and colour temperature (degrees Kelvin; K) with the LuxIQ/2 for 'most comfort' while reading at near were evaluated in-clinic for 71 adults with ocular disease affecting the outer (n = 37; 52%), inner or all retinal layers (n = 34; 48%). Twenty participants received either an OttLite Cobra lamp or a generic gooseneck lamp with a bulb resembling LuxIQ/2 parameters for their preferred reading light, and then completed home-based telephone evaluations using the sustained silent reading test. RESULTS: Participants with outer retinal disease preferred significantly brighter light intensity by an average of 838 lux versus those with inner retinal disease (95% CI: 331, 1344; p = 0.002). No participants opted for a coloured tint for reading based on the LuxIQ/2 measurements since they preferred white light only; most preferred the OttLite Cobra lamp. At home, reading speed improved significantly by an average of 37 words per minute with the new lamp (95% CI: 12, 62; p = 0.005). CONCLUSIONS: Patients with outer retinal disease prefered brighter light intensity for reading. Clinic-based lighting preferences yielded improvements in reading speed when using a new task light at home.

Telerehabilitation for people with low vision.

BACKGROUND: Low vision affects over 300 million people worldwide and can compromise both activities of daily living and quality of life. Rehabilitative training and vision assistive equipment (VAE) may help, but some visually impaired people have limited resources to attend in-person visits to rehabilitation clinics to be trained to learn to use VAE. These people may be able to overcome barriers to care through access to remote, internet-based consultation (telerehabilitation). OBJECTIVES: To compare the effects of telerehabilitation with face-to-face (e.g. in-office or inpatient) vision rehabilitation services for improving vision-related quality of life and near reading ability in people with visual function loss due to any ocular condition. Secondary objectives were to evaluate compliance with scheduled rehabilitation sessions, abandonment rates for VAE devices, and patient satisfaction ratings. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register) (2021, Issue 9); Ovid MEDLINE; Embase.com; PubMed; ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any language restriction or study design filter in the electronic searches; however, we restricted the searches from 1980 onwards because the internet was not introduced to the public until 1982. We last searched CENTRAL, MEDLINE Ovid, Embase, and PubMed on 14 September 2021, and the trial registries on 16 March 2022. SELECTION CRITERIA: We included randomized controlled trials (RCTs) or controlled clinical trials (CCTs) in which participants diagnosed with low vision had received vision rehabilitation services remotely from a human provider using internet, web-based technology compared with an approach involving in-person consultations. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts retrieved by the searches of the electronic databases and then full-text articles for eligible studies. Two review authors independently abstracted data from the included studies. Any discrepancies were resolved by discussion. MAIN RESULTS: We identified one RCT/CCT that indirectly met our inclusion criteria, and two ongoing trials that met our inclusion criteria. The included trial had an overall high risk of bias. We did not conduct a quantitative analysis since multiple controlled trials were not identified.  The single included trial of 57 participants utilized a parallel-group design. It compared 30 hours of either personalized low vision training through telerehabilitation with a low vision therapist (the experimental group) with the self-training standard provided by eSight using the eSkills User Guide that was self-administered by the participants at home for one hour per day for 30 days (the comparison group). The trial investigators found a similar direction of effects for both groups for vision-related quality of life and satisfaction at two weeks, three months, and six months. A greater proportion of participants in the comparison group had abandoned or discontinued use of the eSight Eyewear at two weeks than those in the telerehabilitation group, but discontinuance rates were similar between groups at one month and three months. We rated the certainty of the evidence for all outcomes as very low due to high risk of bias in randomization processes and missing outcome data and imprecision.   AUTHORS' CONCLUSIONS: The included trial found similar efficacy between telerehabilitation with a therapist and an active control intervention of self-guided training in mostly younger to middle-aged adults with low vision who received a new wearable electronic aid. Given the disease burden and the growing interest in telemedicine, the two ongoing studies, when completed, may provide further evidence of the potential for telerehabilitation as a platform for providing services to people with low vision.

Acceptability of Telerehabilitation for Magnification Devices for the Visually Impaired Using Various Approaches to Facilitate Accessibility.

Purpose: We examined different methods to reduce the burden of accessing technology for videoconferencing during telerehabilitation for magnification devices for the visually impaired. Methods: During telerehabilitation studies over the past 5 years, vision rehabilitation providers assessed and gave training to visually impaired participants with newly dispensed magnification devices at home who connected to Zoom videoconferencing via loaner tablets or smartphones with assistance from (phase 1; n = 10) investigators by phone, (phase 2; n = 11) local Lions Club volunteers in participants' homes, or (phase 3; n = 24) remote access control software in a randomized controlled trial with 13 usual care controls who received in-office training. All participants completed the same post-telerehabilitation phone survey. Results: A significantly greater proportion of phase 3 subjects indicated they strongly or mostly agreed that the technology did not interfere with the session (96%) compared to phase 1 (60%; 95% confidence interval [CI], 1.2-12.5; P = 0.03) or phase 2 (55%; 95% CI, 1.8-188; P = 0.01). The majority indicated telerehabilitation was as accurate as in person (68%), they were comfortable with telerehabilitation (91%) and interested in a future session (83%), and their magnifier use improved (79%), with no significant differences in these responses between phases (all P > 0.10), including comparisons of participants randomized to telerehabilitation or in-office training in phase 3 who reported similar overall satisfaction levels (P = 0.84). Conclusions: Participants across all phases reported high levels of acceptance for telerehabilitation, with least interference from technology using remote access control in phase 3. Translational Relevance: With accommodations for accessibility to videoconferencing technology, telerehabilitation for magnification devices can be a feasible, acceptable, and valuable option in countries with resources to support the technology.

Use and Perceptions of Advanced Driver Assistance Systems by Older Drivers With and Without Age-Related Macular Degeneration.

Purpose: Advanced driver assistance systems (ADAS) have been reported to improve the safety of elderly and normally sighted drivers. The purpose of this study was to assess exposure to, perceived safety of, comfort level with, and interest in using ADAS among drivers with age-related macular degeneration (AMD). Methods: Current drivers aged 60+ years were recruited at four US sites to complete a survey about ADAS and driving habits. Frequency of use and/or perceptions of eight ADAS were investigated. An avoidance score was generated using questions about difficult driving situations. Results: The survey was completed by 166 participants (80 with AMD vs. 86 without). Participants with AMD had worse self-rated vision than those without (34% vs. 2% poor or fair rating), and drove fewer weekly miles (median [interquartile range [IQR] 30 [15 to 75] vs. 60 [30 to 121] miles, P = 0.002). Participants with AMD reported more avoidance of difficult driving situations (P < 0.001). There was no difference in the number of ADAS used by AMD status (median [IQR for AMD = 2.5 [1 to 5] vs. 3 [2 to 4] without, P = 0.87). Greater reported number of ADAS used was associated with less avoidance of difficult situations (P = 0.02). The majority perceived improved safety with most ADAS. Conclusions: Many drivers with AMD utilize common ADAS, which subjectively improve their road safety and may help to reduce self-imposed restrictions for difficult situations and mileage. Translational Relevance: Drivers with AMD are adopting readily available ADAS, for which they reported potential benefits, such as safety and less restrictive driving.

Bluetooth Low Energy Beacon Sensors to Document Handheld Magnifier Use at Home by People with Low Vision.

We explored the feasibility of using Bluetooth low energy (BLE) beacon sensors to determine when individuals with low vision (LV) use handheld magnifiers at home. Knowing the frequency and duration of magnifier use would be helpful to document increased magnifier use after successful rehabilitation training, or conversely, to know when someone has abandoned a magnifier and requires assistance. Estimote Sticker BLE beacon sensors were attached to the handles of optical handheld magnifiers and dispensed to eight LV subjects to use at home. Temperature and motion data from the BLE beacon sensors were collected every second by a custom mobile application on a nearby smartphone and transmitted to a secure database server. Subjects noted the date and start/end times of their magnifier use in a diary log. Each of the 99 diary-logged self-reports of magnifier use across subjects was associated with BLE beacon sensor recordings of motion (mean 407 instances; SD 365) and increased temperature (mean 0.20 °C per minute; SD 0.16 °C) (mean total magnitude 5.4 °C; SD 2.6 °C). Diary-logged duration of magnifier use (mean 42 min; SD 24) was significantly correlated with instances of motion (p < 0.001) and rate of temperature increase (p < 0.001) recorded by the BLE beacon sensors. The BLE beacon sensors reliably detected meaningfully increased temperature, coupled with numerous instances of motion, when magnifiers were used for typical reading tasks at home by people with LV.

A Unified Rule for Binocular Contrast Summation Applies to Normal Vision and Common Eye Diseases.

Purpose: Binocular summation refers to better visual performance with two eyes than with one eye. Little is known about the mechanism underlying binocular contrast summation in patients with common eye diseases who often exhibit binocularly asymmetric vision loss and structural changes along the visual pathway. Here we asked whether the mechanism of binocular contrast summation remains preserved in eye disease. Methods: This study included 1035 subjects with normal ocular health, cataract, age-related macular degeneration, glaucoma, and retinitis pigmentosa. Monocular and binocular contrast sensitivity were measured by the Pelli-Robson contrast sensitivity chart. Interocular ratio (IOR) was quantified as the ratio between the poorer and better eye contrast sensitivity. Binocular summation ratio (BSR) was quantified as the ratio between binocular and better eye contrast sensitivity. Results: All groups showed statistically significant binocular summation, with the BSR ranging from 1.25 [1.20, 1.30] in the glaucoma group to 1.31 [1.27, 1.36] in the normal vision group. There was no significant group difference in the BSR, after accounting for IOR. By fitting a binocular summation model Binocular = (Leftm + Rightm)1/m to the contrast sensitivity data, we found that the same binocular summation rule, reflected by the parameter m, applies across the five groups. Conclusions: Cortical binocular contrast summation appears to be preserved in spite of eye diseases that can affect the two eyes differently. This finding supports the importance of assessing both monocular and binocular functions, rather than relying on a monocular assessment in the better eye as a potentially inaccurate surrogate measure.

Validation of Computer-Adaptive Contrast Sensitivity as a Tool to Assess Visual Impairment in Multiple Sclerosis Patients.

BACKGROUND: Impairment of visual function is one of the major symptoms of people with multiple sclerosis (pwMS). A multitude of disease effects including inflammation and neurodegeneration lead to structural impairment in the visual system. However, the gold standard of disability quantification, the expanded disability status scale (EDSS), relies on visual assessment charts. A more comprehensive assessment of visual function is the full contrast sensitivity function (CSF), but most tools are time consuming and not feasible in clinical routine. The quantitative CSF (qCSF) test is a computerized test to assess the full CSF. We have already shown a better correlation with visual quality of life (QoL) than for classical high and low contrast charts in multiple sclerosis (MS). OBJECTIVE: To study the precision, test duration, and repeatability of the qCSF in pwMS. In order to evaluate the discrimination ability, we compared the data of pwMS to healthy controls. METHODS: We recruited two independent cohorts of MS patients. Within the precision cohort (n = 54), we analyzed the benefit of running 50 instead of 25 qCSF trials. The repeatability cohort (n = 44) was assessed by high contrast vision charts and qCSF assessments twice and we computed repeatability metrics. For the discrimination ability we used the data from all pwMS without any previous optic neuritis and compared the area under the log CSF (AULCSF) to an age-matched healthy control data set. RESULTS: We identified 25 trials of the qCSF algorithm as a sufficient amount for a precise estimate of the CSF. The median test duration for one eye was 185 s (range 129-373 s). The AULCSF had better test-retest repeatability (Mean Average Precision, MAP) than visual acuity measured by standard high contrast visual acuity charts or CSF acuity measured with the qCSF (0.18 vs. 0.11 and 0.17, respectively). Even better repeatability (MAP = 0.19) was demonstrated by a CSF-derived feature that was inspired by low-contrast acuity charts, i.e., the highest spatial frequency at 25% contrast. When compared to healthy controls, the MS patients showed reduced CSF (average AULCSF 1.21 vs. 1.42, p < 0.01). CONCLUSION: High precision, usability, repeatability, and discrimination support the qCSF as a tool to assess contrast vision in pwMS.

Improvements in Test-Retest Variability of Static Automated Perimetry by Censoring Results With Low Sensitivity in Retinitis Pigmentosa.

Purpose: We evaluated whether omitting (censoring) points in more severely damaged visual field areas can reduce test-retest variability of static automated perimetry (SAP) in retinitis pigmentosa (RP), as variability creates a significant challenge when monitoring for changes. Methods: Cohort 1 included 27 eyes in 16 RP subjects with visual acuity (VA) ranging from 20/20 to 20/70 who completed Humphrey 10-2 size III SAP, once per visit at three visits. Cohort 2 included 15 eyes in nine RP subjects with VA ≤ 20/60 who completed Humphrey 30-2 size V SAP, twice per visit at three visits. Variability was assessed using 95% coefficient of repeatability (CR) calculations for uncensored (all threshold values and data points included) and censored data. Results: In cohort 1, the uncensored between-visit 95% CR was 11.6 decibels (dB); censoring locations with threshold values of <8 to 20 dB resulted in 31% to 53% reductions in the 95% CR. For cohort 2, uncensored 95% CRs were 8.7 and 8.0 dB for within- and between-visit variability, respectively; censoring <8 to 17 dB resulted in 15% to 41% and 15% to 43% reductions in within-visit and between-visit 95% CRs, respectively. For both cohorts, censoring at higher values yielded slightly less variability, at the expense of discarding data from a greater number of eyes and test locations. Conclusions: For 20/20 to 20/70 VA tested with size III stimuli, censoring lower sensitivity values results in substantially lower test-retest variability, which may help detect true changes for locations without severe baseline loss. Translational Relevance: A rule of thumb for clinical practices using SAP to monitor RP is that longitudinal losses of >9 dB for individual test locations with initial values ≥ 9 dB are likely to be real and meaningful, as they exceed typical variability.

Telerehabilitation for people with low vision.

BACKGROUND: Low vision affects over 300 million people worldwide and can compromise both activities of daily living and quality of life. Rehabilitative training and vision assistive equipment (VAE) may help, but some visually impaired people have limited resources to attend in-person visits at rehabilitation clinics to receive training to learn to use VAE. These people may be able to overcome barriers to care through remote, Internet-based consultation (i.e. telerehabilitation). OBJECTIVES: To compare the effects of telerehabilitation with face-to-face (e.g. in-office or inpatient) vision rehabilitation services for improving vision-related quality of life and near reading ability in people with visual function loss due to any ocular condition. Secondary objectives were to evaluate compliance with scheduled rehabilitation sessions, abandonment rates for VAE devices, and patient satisfaction ratings. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2019, Issue 6); Ovid MEDLINE; Embase.com; PubMed; ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any language restriction or study design filter in the electronic searches; however, we restricted the searches from 1980 onwards because the Internet was not introduced to the public until 1982. We last searched the electronic databases on 24 June 2019. SELECTION CRITERIA: We planned to include randomized controlled trials (RCTs) or controlled clinical trials (CCTs) in which participants diagnosed with low vision were undergoing low vision rehabilitation using an Internet, web-based technology compared with an approach involving in-person consultations. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts and then full-text articles against the eligibility criteria. We planned to have two review authors independently abstract data from the included studies. Any discrepancies were resolved by discussion. MAIN RESULTS: We identified two ongoing studies, but did not find any completed RCTs and CCTs that met the inclusion criteria for this review. We did not conduct a quantitative analysis. We discussed review articles on telemedicine for facilitating communication with elderly individuals or for providing remote ophthalmological care. AUTHORS' CONCLUSIONS: We did not find any evidence from RCTs or CCTs on the efficacy of using telerehabilitation for remote delivery of rehabilitation services to individuals with low vision. Given the disease burden and the growing interest in telemedicine, the two ongoing studies, when completed, may provide evidence in understanding the potential for telerehabilitation as a platform for providing services to people with low vision.

U.S. Optometrists' Reported Practices and Perceived Barriers for Low Vision Care for Mild Visual Loss.

SIGNIFICANCE: Identification of modifiable barriers to low vision rehabilitation (LVR) can inform efforts to improve practice management of patients with low vision (LV), through, for example, targeted educational programs for optometrists who do not practice LVR. PURPOSE: Mild vision loss (20/25 to 20/70) is increasing in prevalence among the aging population, yet it is unclear whether near-reading complaints (the highest presenting chief complaint) are being addressed. Studies of LVR provision by U.S. optometrists are currently lacking. This study elucidated self-reported optometric practice patterns for patients with mild vision loss. METHODS: Anonymous surveys were completed by 229 actively practicing optometrists across the United States. The survey inquired about the frequency of providing LVR for mild vision loss patients and the top barriers that prevent them from offering LVR management (including optical aids or referral). RESULTS: Compared with those moderately actively practicing LVR, twice as many (2.08×) practitioners who do not practice any LVR reported that they never prescribe near-reading add power of 4 D or greater for mild vision loss (P < .001). Among those who do not practice LVR, 39 and 11% indicated that they never prescribe any LVR management strategies for patients with visual acuity of 20/25 to 20/40 and 20/50 to 20/70, respectively. The two most commonly reported barriers to LVR indicated by about half of respondents were "cost of the LV exam and/or devices" and that "patients are not interested or would not go to an LV exam." Nearly a third of providers reported that "it is not feasible to stock magnifiers in office." CONCLUSIONS: A sizable group of non-LVR providers in the United States may not be addressing the near-vision needs of patients with mild vision loss. Several of the reported top barriers are potentially modifiable through the development of targeted educational programs for providers.

Reliability of Mesopic Measures of Visual Acuity and Contrast Sensitivity and Their Correlation with Rod and Cone Function in Retinitis Pigmentosa.

BACKGROUND: Mesopic conditions elicit both rod and cone responses, and they are more commonly encountered in daily life than are scotopic conditions; yet visual function outcome measures of mesopic visual acuity (VA) or contrast sensitivity (CS) are rarely evaluated. OBJECTIVE: In retinitis pigmentosa (RP), we explored whether visual reductions in mesopic versus photopic conditions were correlated with cone or rod function, as well as the between-visit test-retest variability in mesopic measures. METHODS: At each of two visits, 22 RP subjects completed mesopic and photopic ETDRS VA and Pelli-Robson chart CS tests obtained with and without a U23 NoIR 4% transmission filter; testing of perifoveal scotopic cone or rod sensitivity with the AdaptDx; and the Rabin Cone Contrast Test (CCT). RESULTS: A greater CS reduction in mesopic versus photopic conditions was significantly related to absence of scotopic rod function (p = 0.038) or longer self-reported duration of night vision loss (p = 0.044). VA reductions >0.2 logMAR in mesopic versus photopic conditions were significantly related to reduced cone-mediated scotopic sensitivity (p = 0.038). Significant predictors of the CCT ratio of S-cone to M- and L-cone sensitivity were mesopic VA (p = 0.038) and absence of AdaptDx rod function (p = 0.008). Test-retest 95% coefficients of repeatability were not significantly different when comparing between photopic and mesopic tests of VA (0.16 and 0.12 logMAR, respectively) or CS (0.21 and 0.24 logCS, respectively). CONCLUSIONS: Perifoveal scotopic rod and cone function measured with the AdaptDx was significantly correlated with mesopic CS and VA, respectively, which had good, acceptable test-retest repeatability; thus, they appear to be suitable outcome measures to monitor mesopic visual function in clinical practice or trials. RP subjects with reduced mesopic VA and no perifoveal rod function had a greater loss of sensitivity for S-cones than for L-/M-cones.

Relationship Between Acuity and Contrast Sensitivity: Differences Due to Eye Disease.

Purpose: Visual acuity (VA) and contrast sensitivity (CS) characterize different aspects of visual function. Whereas VA is a standard test in routine eye exams and clinical trials, CS is often not included. We investigated the pathology-specific dissociation between VA and CS by quantifying and comparing the relationship between these two measures in common ocular pathologies. Methods: VA and CS data were assembled from 1113 subjects, including groups with cataract (n = 450), age-related macular degeneration (AMD; n = 232), glaucoma (n = 100), retinitis pigmentosa (RP; n = 87), and normal ocular health (n = 244). VA and CS were measured by the Early Treatment Diabetic Retinopathy Study chart and Pelli-Robson chart, respectively. Results: Even when VA was relatively normal (<0.3 logMAR), the four ocular pathology groups showed quantitatively different mean CS deficits relative to normal controls, ranging from -0.01 log units for cataract to 0.23 log units for RP. When the entire range of VA was considered, the corresponding deficits in CS were noticeably different across these four groups, being least for cataract and progressively more severe for glaucoma, AMD, and RP. For every 1.0 logMAR loss of VA, the corresponding deficit in CS ranged from 0.22 logCS for cataract to 0.97 logCS for RP. Conclusions: The quantitative relationship between VA and CS depends on the ocular pathology. CS appears to provide valuable complementary information to VA in the early detection of eye disease and when evaluating visual impairment.

Reliability of Semiautomated Kinetic Perimetry (SKP) and Goldmann Kinetic Perimetry in Children and Adults With Retinal Dystrophies.

PURPOSE: To investigate the precision of visual fields (VFs) from semiautomated kinetic perimetry (SKP) on Octopus 900 perimeters, for children and adults with inherited retinal degenerations (IRDs). Goldmann manual kinetic perimetry has long been used in the diagnosis and follow-up of these patients, but SKP is becoming increasingly common. Octopus VFs (OVFs) and Goldmann VFs (GVFs) were both mapped on two occasions. METHODS: Nineteen females and 10 males with IRDs were tested on OVFs and GVFs, with two targets per test (V4e and one smaller target). Tests were performed in the same (randomized) order at two visits about 1 week apart. The VFs were digitized to derive isopter solid angles. Comparisons, within and between visits, were performed with paired t-tests and Bland-Altman plots. RESULTS: Median age was 20 years (range, 7-70; 10 participants aged ≤17 years old). There were no significant differences in solid angles between OVFs and GVFs (P ≥ 0.06) or between the two visits' solid angles on either perimeter (P ≥ 0.30). Between-visit test-retest variability for GVFs and OVFs was similar (P ≥ 0.73), with median values of approximately 9% to 13%. Overall variability was lower for children than adults (medians of 7.5% and 12.8%, respectively). CONCLUSIONS: Octopus SKP and Goldmann perimetry produced VFs of similar size and variability. TRANSLATIONAL RELEVANCE: Our study indicates that SKP provides a viable alternative to traditional Goldmann perimetry in clinical trials or care involving both children and adults with IRDs.

PREVALENCE OF VITREOMACULAR ADHESION IN PATIENTS WITHOUT MACULOPATHY OLDER THAN 40 YEARS.

PURPOSE: To determine the prevalence and factors influencing vitreomacular adhesion (VMA) or vitreomacular traction (VMT) in subjects without maculopathy older than age 40 years. METHODS: In a prospective cross-sectional study, 1,950 eyes in 1,090 participants aged 40 to 89 years representing various ethnic groups from 14 centers in the United States underwent a comprehensive eye examination, including spectral domain optical coherence tomography. A team of independent, masked readers classified the presence or absence of VMA/VMT on spectral domain optical coherence tomography based on the International Vitreomacular Traction Study Group rubric. RESULTS: Across all eyes, the prevalence of VMA or VMT was 39% or 1%, respectively. For every 1-year increase in age, there was a statistically significant 7% decreased odds of having VMA or VMT (95% confidence interval [CI]: 0.89-0.96; P < 0.001), whereas African Americans had 55% significantly reduced odds of having VMA or VMT when than whites (95% CI: 0.23-0.90; P = 0.025). Vitreomacular adhesion >1,500 µm was significantly more likely than VMA <1,500 µm in younger adults (95% CI: 0.70-0.86; P < 0.001), hyperopes versus emmetropes (95% CI: 1.49-35.9; P = 0.01), primary eye care versus tertiary practices (95% CI: 0.03-0.92; P = 0.04), and patients without hyperlipidemia (95% CI: 0.04-0.83; P = 0.03). CONCLUSION: Vitreomacular adhesion is highly prevalent among middle-aged adults. Diagnostic screening with spectral domain optical coherence tomography may help to accurately detect VMA or VMT, prompting routine monitoring and timely therapeutic intervention.

Randomized controlled trial of electro-stimulation therapies to modulate retinal blood flow and visual function in retinitis pigmentosa.

PURPOSE: We examined changes in visual function and ocular and retinal blood flow (RBF) among retinitis pigmentosa (RP) participants in a randomized controlled trial of electro-stimulation therapies. METHODS: Twenty-one RP participants were randomized (1:1:1) to transcorneal electrical stimulation (TES) at 6 weekly half-hour sessions, electro-acupuncture or inactive laser acupuncture (sham control) at 10 half-hour sessions over 2 weeks. Early Treatment of Diabetic Retinopathy Study (ETDRS) visual acuity (VA), quick contrast sensitivity function, Goldmann visual fields, AdaptDx scotopic sensitivity, spectral flow and colour Doppler imaging of the central retinal artery (CRA), and RBF in macular capillaries were measured twice pre-treatment, after 2 TES sessions, within a week and a month after intervention completion. RESULTS: We measured a significant improvement in retrobulbar CRA mean flow velocity for both the TES (p = 0.038) and electro-acupuncture groups (p = 0.001) on average after 2 weeks of treatment when compared to sham controls. Transcorneal electrical simulation (TES) and electro-acupuncture subjects had significant 55% and 34% greater increases, respectively, in RBF in the macular vessels when compared to sham controls (p < 0.001; p = 0.008) within a week of completing six TES sessions or a month after electro-acupuncture. There was a significant difference in the proportion of eyes that had improved visual function when comparing the three intervention groups (p = 0.038): four of seven TES subjects (57%), two of seven electro-acupuncture subjects (29%) and none of the seven control subjects (0%) had a significant visual improvement outside of typical test-retest variability at two consecutive post-treatment visits. CONCLUSION: Increased blood flow following electro-stimulation therapies is an objective, physiological change that occurred in addition to visual function improvements in some RP patients.