Age-related eye disease and cognitive function.

PURPOSE: To determine whether people with age-related eye disease have lower cognitive scores than people with healthy vision. METHODS: A hospital-based cross-sectional study was performed in which 420 people aged 65 and older from the ophthalmology clinics at Maisonneuve-Rosemont Hospital (Montreal, Canada) were recruited who had age-related macular degeneration (AMD), Fuch's corneal dystrophy, or glaucoma. Patients with AMD and Fuchs had to have visual acuity in the better eye of worse than 20/40 while patients with glaucoma had to have visual field in their worse eye of at least -4 dB. Controls, recruited from the same clinics, did not have significant vision loss. Cognitive status was measured using the Mini-Mental State Exam Blind Version (range, 0-22) which excludes eight items that rely on vision. Linear regression with bootstrapped standard errors was used to adjust for demographic and medical factors. RESULTS: People with AMD, Fuch's corneal dystrophy, and glaucoma had lower cognitive scores, on average, than controls (P < 0.05). These relationships remained statistically significant after adjusting for factors such as age, sex, race, education, living alone, systemic comorbidities, and lens opacity. CONCLUSIONS: People with vision loss due to three different age-related eye diseases had lower cognitive scores. Reasons for this should be explored using longitudinal studies and a full battery of cognitive tests that do not rely on vision.

The Perceived Needs and Availability of Eye Care Services for Older Adults in Long-term Care Facilities.

BACKGROUND: The objective was to evaluate the eye care services offered to older residents living in long-term care facilities (LTCFs). METHODS: A questionnaire targeting residents aged ≥65 years was sent to all LTCFs in Quebec. Questions related to the institution's characteristics, demographic data related to residents, oculovisual health of residents and barriers to eye care, eye care services offered within and outside the institution, and degree of satisfaction regarding the eye care services offered to residents. RESULTS: 196/428 (45.8%) LTCFs completed the questionnaire. Participating LTCFs had an average of 97.0 ± 5.1 residents with a mean age of 82.8 ± 3.0 yrs and 69% women. Eye care services were mostly offered outside the institution, on a "per request" basis. The main barriers to eye care were the perception that residents could not cooperate and the lack of eye care professionals. Most LTCFs were satisfied with the eye care services offered to residents. CONCLUSIONS: The fact that the LTCFs were satisfied with the eye care services offered to their residents, although it was neither provided on a regular basis nor to all residents, suggests that eye care professionals should take a proactive educational role for improving services to older institutionalized adults.

Activity limitation due to a fear of falling in older adults with eye disease.

PURPOSE: To examine whether patients with age-related macular degeneration (AMD), glaucoma, or Fuchs corneal dystrophy report limiting their activity due to a fear of falling as compared with a control group of older adults with good vision. METHODS: We recruited 345 patients (93 with AMD, 57 with Fuchs, 98 with glaucoma, and 97 controls) from the ophthalmology clinics of Maisonneuve-Rosemont Hospital (Montreal, Canada) to participate in a cross-sectional study from September 2009 until July 2012. Control patients who had normal visual acuity and visual field were recruited from the same clinics. Participants were asked if they limited their activity due to a fear of falling. Visual acuity, contrast sensitivity, and visual field were measured and the medical record was reviewed. RESULTS: Between 40% and 50% of patients with eye disease reported activity limitation due to a fear of falling compared with only 16% of controls with normal vision. After adjustment for age, sex, race, number of comorbidities, cognition, and lens opacity, the Fuchs groups was most likely to report activity limitation due to a fear of falling (odds ratio [OR] = 3.07; 95% confidence interval [CI], 1.33-7.06) followed by the glaucoma group (OR = 2.84; 95% CI, 1.36-5.96) and the AMD group (OR = 2.42; 95% CI, 1.09-5.35). Contrast sensitivity best explained these associations. CONCLUSIONS: Activity limitation due to a fear of falling is very common in older adults with visually impairing eye disease. Although this compensatory strategy may protect against falls, it may also put people at risk for social isolation and disability.

Explaining the relationship between three eye diseases and depressive symptoms in older adults.

PURPOSE: The purpose of this study is to examine whether patients with age-related eye diseases, like age-related macular degeneration (AMD), glaucoma, or Fuchs corneal dystrophy, are more likely to show signs of depression compared to a control group of older adults with good vision, and to determine whether reduced mobility mediates these relationships. METHODS: We recruited 315 eligible patients (81 with AMD, 55 with Fuchs, 91 with glaucoma, and 88 controls) from the ophthalmology clinics of a Montreal hospital from September 2009 until December 2011. Depressive symptoms were assessed using the Geriatric Depression Scale Short Form (GDS-15). Life space was measured using the Life Space Assessment. Logistic regression was used to adjust for demographic, health, and social factors, and mediation was assessed using the methods of Baron and Kenny. RESULTS: There were 78 people (25%) meeting the criteria for depression in the cohort. All three groups with eye disease were more likely to be depressed than the control group after adjusting for age, sex, ethnicity, education, cognitive score, limitations in activities of daily living, social support, and lens opacity (P < 0.05). Life space and limited activities due to a fear of falling appeared to mediate the relationship between eye disease and depression. CONCLUSIONS: Visually limiting eye disease is associated with depression in older adults. Further research on interventions to prevent depression in patients with eye disease is warranted and should consider strategies to alleviate mobility limitation. Greater attention from families, physicians, and society to the mental health needs and mobility challenges of patients with eye disease is needed.

Age-related eye disease and mobility limitations in older adults.

PURPOSE: To examine the extent of mobility limitations in patients with age-related macular degeneration (AMD), glaucoma, or Fuchs' corneal dystrophy compared with that in a control group of older adults with good vision. METHODS: Two hundred seventy-two patients (68 with AMD, 49 with Fuchs' dystrophy, 82 with glaucoma, and 73 controls) from the ophthalmology clinics of Maisonneuve-Rosemont Hospital (Montreal, Canada) participated in a cross-sectional study from September 2009 until February 2011. Control patients who had normal visual acuity and visual fields were recruited from the same clinics. Questionnaire (life space, falls, and driving) and performance-based (one-legged balance test, Timed Up and Go [TUG] test) mobility data were collected; visual acuity, contrast sensitivity, and visual field were measured; and the medical record was reviewed. RESULTS: The three eye diseases were associated with different patterns of mobility limitations. Patients with glaucoma had the most types of mobility limitations, as they had reduced life-space scores, had worse TUG scores, were less likely to drive, and were more likely to have poor balance than the control group (P < 0.05). Compared with the controls, patients with AMD and Fuchs' corneal dystrophy had reduced life-space scores and were less likely to drive (P < 0.05). CONCLUSIONS: The results suggest that eye diseases, especially glaucoma, restrain the mobility of older people in many different ways. It is important to further explore the impact of eye disease on mobility in this population, to develop interventions that could help affected older adults maintain their independence.

Combining rim area to disc area asymmetry ratio and Moorfields regression analysis of confocal scanning laser ophthalmoscopy for glaucoma screening.

OBJECTIVE: To determine the utility of combining rim area to disc area asymmetry ratio (RADAAR) and Moorfields regression analysis (MRA) to detect primary open-angle glaucoma (POAG) using confocal scanning laser ophthalmoscopy (CSLO) (Heidelberg retina tomograph 3 (HRT3)) in high-risk populations. DESIGN: Cross-sectional study. PARTICIPANTS: Subjects with high risk for developing POAG. METHODS: Subjects underwent HRT, frequency doubling technology perimetry (FDT), and complete ophthalmic examination. Based on an ophthalmologic examination and FDT results of the worse eye, subjects were classified into 4 categories: normal, possible glaucoma, probable glaucoma, and definite glaucoma. Main outcome measures included sensitivities (Se), specificities (Sp), positive and negative predictive values (PPV, NPV), and positive and negative likelihood ratios (PLR, NLR) of the MRA, RADAAR, and combined MRA- RADAAR tests. RESULTS: Of 375 subjects, 11 were classified as having definite glaucoma. Depending on the reference standard, range results for Se, Sp, PPV, NPV, PLR, and NLR were, respectively, 57.7% to 100%; 55.1% to 85.4%; 6.3% to 39%; 92.6% to 100%; 1.97 to 4.9; 0 to 0.49 for MRA; 11.5% to 27.3%; 98.1% to 98.8%; 30% to 60%; 87.4% to 97.8%; 9.29 to 14.1; and 0.74 to 0.89 for RADAAR; and 57.7% to 90.9%; 81.3% to 85.1%; 12.8% to 38.5%; 92.6% to 99.7%; 3.87 to 4.85; 0.11 to 0.50 for combination MRA-RADAAR. DISCUSSION: When using HRT in populations at high risk for glaucoma, RADAAR had a higher specificity than MRA in identifying glaucoma. When patients were classified as borderline on MRA, combining RADAAR values decreased the number of false-positives as well, and may be recommended when high specificity is required.

Association between unilateral quiescent stromal herpetic keratitis and bilateral dry eyes.

PURPOSE: According to our clinical observation, patients with quiescent herpes simplex virus (HSV) stromal keratitis often seem to present with signs of dry eye in the contralateral eye. Our goal was to compare dry eye signs and symptoms in both eyes of patients with quiescent HSV stromal keratitis with those of age- and sex-matched control subjects with healthy corneas. METHODS: A case-control study with 24 subjects per group. RESULTS: The average age of 10 men and 14 women in each group was 58 years. The HSV eye of cases was first compared with the contralateral eye with a healthy cornea. As expected, the HSV eye had a significantly lower corneal sensation threshold (P = 0.001); no significant difference was however found for Schirmer tests done with anesthesia (basal tear secretion) and without anesthesia, tear breakup time, mucus and debris in the tear film, and eyelid margin redness or swelling. Then, the HSV eye of cases was compared with the right eye of controls, whereas the healthy eye of cases was compared with the left eye of controls. Patients with unilateral quiescent HSV stromal keratitis had significantly lower bilateral Schirmer tests both with anesthesia (P = 0.001) and without anesthesia (P = 0.02). Dry eye symptoms of the healthy cornea of cases and those of controls did not differ significantly. CONCLUSIONS: Both eyes of patients with quiescent HSV stromal keratitis in our population were dry even if many patients with HSV stromal keratitis did not have symptoms in their fellow eye.

Economic impact of the advent of posterior lamellar keratoplasty in Montreal, Quebec.

OBJECTIVE: To assess the cost-utility of posterior lamellar keratoplasty (PLK) techniques, including deep lamellar endothelial keratoplasty, Descemet stripping endothelial keratoplasty, and Descemet stripping automated endothelial keratoplasty, in the treatment of corneal endothelial diseases. DESIGN: Cost-utility analysis based on a Markov model. PARTICIPANTS: Cohort of 100 patients waiting for corneal graft. METHODS: This cost-utility analysis was performed from a Canadian health system perspective over a lifetime period. A Markov model was constructed to compare the cost per quality-adjusted life-year (QALY) associated with penetrating keratoplasty (PK) and PLK techniques. The model included all major health states relevant to patients scheduled for corneal transplant: waiting for transplant, surviving graft with or without complications, irreversible failure, noneligibility, and death. Transition probabilities among health states were obtained from published clinical trials. Costs considered were those associated with surgery, patients' follow-up, and postsurgical complications. Number of QALYs was estimated presurgery and postsurgery using the Brown and Sharma conversion chart. RESULTS: PLK proved to be more effective, providing more QALYs (+13 QALYs/100 patients), and it was less costly (-$68,792/100 patients) compared with PK. Deterministic and probabilistic sensitivity analyses confirmed the robustness of the base-case results. CONCLUSIONS: From a clinical and an economic standpoint, PLK in the management of patients waiting for corneal graft represents a preferred strategy compared with PK only.

Optical coherence tomography anatomy of the corneal endothelial transplantation wound.

PURPOSE: The goal of this study was to prospectively assess the deep lamellar endothelial keratoplasty (DLEK) wound anatomy and its evolution during the 12 months after surgery, using optical coherence tomography (OCT). METHODS: The eyes of 8 patients (1 eye per patient) who consecutively underwent DLEK for Fuchs dystrophy or pseudophakic bullous keratopathy were prospectively studied before and 1, 3, 6, and 12 months after surgery. The Stratus OCT apparatus (Carl Zeiss Meditec, Dublin, CA) was used to acquire central and radial scans perpendicular to the wound at 3-, 6-, 9-, and 12-o'clock positions. The following parameters were analyzed: central total thickness, posterior donor-recipient edges gap, donor-recipient height mismatch, tissue compression, and graft detachment. RESULTS: A posterior gap was observed in 4 of the 8 DLEK eyes. At 12 months, the mean gap contour, depth, and width were 242 +/- 67, 101 +/- 45, and 87 +/- 29 microm, respectively. A step was documented in all DLEK eyes (average step height 108 +/- 24 microm). A micrograft detachment was observed in one case and tissue compression in another. In all corneas, the mean central corneal thickness returned to normal range and almost normal anatomy with time after surgery. CONCLUSIONS: OCT was found to be a very useful tool for DLEK corneal wound architecture analysis. It revealed microscopic wound irregularities and allowed their quantitative follow-up with time.

Reducing wait time for cataract surgery: comparison of 2 historical cohorts of patients in Montreal.

OBJECTIVE: A cataract efficiency program was implemented in Montreal in 2003 to decrease surgery wait time. Our goal was to determine whether health, adverse events during wait time, and outcome of patients presenting for cataract surgery differed from 1999 to 2006 in Montreal. DESIGN: Prospective preoperative and postoperative observational study performed at 2 time points 6 years apart. PARTICIPANTS: Patients awaiting first-eye cataract surgery at Maisonneuve-Rosemont Hospital: 509 patients in 1999-2000 and 206 patients in 2006-2007. METHODS: Patients awaiting first-eye cataract surgery were recruited from Maisonneuve-Rosemont Hospital in 1999-2000 (n = 509) and a second cohort was recruited in 2006-2007 (n = 206). Date of entry onto the hospital waiting list and date of cataract surgery were recorded. About 2 weeks before surgery, patients were asked about accidents and falls while waiting, visual difficulty, and satisfaction with vision and wait time. Visual acuity was measured in each eye. Patients also completed interviewer-administered questionnaires: the 5-item Cataract Symptom Scale, Visual Function-14 Questionnaire (VF-14), Short Form Health Survey-36, Geriatric Depression Scale, and the 14-item Systemic Comorbidity Scale. The interview was repeated after surgery. RESULTS: In 1999, 39% of patients waited more than 6 months for cataract surgery, and this was reduced to 29% in 2006. Patients had better preoperative visual acuity in the surgical eye, less visual difficulty, and fewer cataract symptoms, and reported fewer accidents while waiting for surgery in 2006. The change in visual acuity after surgery was nonetheless the same in the 2 cohorts. The 2006 cohort achieved significantly higher VF-14 scores and reported more satisfaction with vision after surgery than did the 1999 cohort. CONCLUSIONS: Patients had cataract surgery sooner in the disease process in 2006-2007 compared with 1999-2000, with changes in visual acuity after surgery that were clinically significant in both cohorts.

Rate of endophthalmitis after cataract surgery in quebec, Canada, 1996-2005.

OBJECTIVE: To estimate the annual incidence of endophthalmitis after cataract surgery from January 1, 1996, through December 31, 2005, in Quebec, Canada. METHODS: Deidentified data were obtained from an outpatient physician billing database (Quebec State Control for Health Insurance [RAMQ]) with regard to all cataract surgical procedures performed from January 1, 1996, through December 31, 2005, in Quebec. For this cohort, records of an International Classification of Diseases, Ninth Revision (ICD-9) code for endophthalmitis during the same years were requested from 2 sources: the RAMQ outpatient database and an inpatient hospital discharge database (Maintenance and Exploitation of Data for the Study of Hospitalized Patients [MED-ECHO]). Endophthalmitis after cataract surgery was assumed if it occurred within 90 days of the surgery. Risk factors were examined using chi(2) tests and logistic regression. RESULTS: After exclusions, 490 690 cataract surgical procedures were performed from January 1, 1996, through December 31, 2005. A total of 754 cases of endophthalmitis occurred within 90 days after surgery for an overall incidence rate of 1.5 per 1000 surgical procedures (95% confidence interval [CI], 1.4-1.7). Factors associated with endophthalmitis included age of 85 years or older (odds ratio [OR], 1.34; 95% CI, 1.06-1.70), male sex (1.44; 1.24-1.66), later year of surgery (0.94; 0.92-0.97), and region of cataract surgery, because regions 6 (2.21; 1.91-2.55) and 9 (4.00; 2.48-6.43) had higher rates compared with all other regions. CONCLUSION: Reasons that explain the apparent decrease in endophthalmitis, especially in 2005, should be explored and further research performed to understand why certain patients and regions have higher risks of endophthalmitis after cataract surgery.

Cataract-related vision loss and depression in a cohort of patients awaiting cataract surgery.

OBJECTIVE: As provinces consider what an acceptable cataract surgery wait time should be, research is needed on the risk of adverse events, such as depression, while waiting for care. We sought to determine whether worse visual acuity is related to depressive symptoms in patients waiting to have cataract surgery. DESIGN: Cohort study. PARTICIPANTS: Six hundred seventy-two patients awaiting cataract surgery were recruited from Maisonneuve-Rosemont Hospital in Montreal, Que. METHODS: About 2 weeks before surgery and 4 months after surgery, patients completed the Visual Function-14 questionnaire, a measure of the self-report of difficulty performing visual tasks, and the 30-item Geriatric Depression Scale. Patients were also asked about systemic and ocular comorbidities. Visual acuity was measured with pinhole correction. Date of entry onto the hospital waiting list and date of cataract surgery were recorded. RESULTS: Forty-one percent of patients had visual acuity of 6/18 or worse in the surgical eye, whereas 26% showed signs of depression before surgery (Geriatric Depression Scale-30 > or = 10). In a logistic regression model, those with visual acuity < or = 6/18 in their surgical eye had a 59% higher adjusted odds of depression (odds ratio 1.59, 95% CI 1.09-2.33). There was statistically significant evidence that the relationship between visual acuity and depression was mediated by greater reported difficulty on the Visual Function-14 (p < 0.05). CONCLUSIONS: Patients with worse visual acuity were more likely to be depressed while waiting for cataract surgery. Shortening the wait time for cataract surgery, especially for those with worse vision, could potentially reduce the risk or shorten the duration of depression.

Using the CanMEDS roles when interviewing for an ophthalmology residency program.

BACKGROUND: To improve the admissions process for the Université de Montréal (UdeM) ophthalmology residency program, the interview structure was modified to encompass the seven CanMEDS roles introduced by the Royal College of Physicians and Surgeons of Canada (RCPSC). These roles include an applicant's abilities as a communicator, collaborator, manager, health advocate, professional, scholar, and medical expert. METHODS: In this retrospective pilot study, the records of all applicants were reviewed by 8 members of the admissions committee, with a high intraclass correlation coefficient of 0.814. Four 2-person interview teams were then formed. The first 3 groups asked the applicants specific questions based on 2-3 of the CanMEDS roles, marking their impressions of each candidate on a visual analogue scale. The last group answered candidates' questions about the program but assigned no mark. RESULTS: The intraclass correlations for the teams were 0.900, 0.739, and 0.585, demonstrating acceptable interrater reliability for 2 of the teams. Pearson correlation coefficients between groups of interviewers were considered adequate at 0.562, 0.432, and 0.417 (p < 0.05). For each interviewer, the Pearson correlation coefficient between record marking and interview scoring was either not statistically significant or very low. INTERPRETATION: By basing the 2006 interview process on the CanMEDS roles defined by the RCPSC, information was obtained about the candidates that could not have been retrieved by a review of the medical students' records alone. Reliability analysis confirmed that this new method of conducting interviews provided sound and reliable judging and rating consistency between all members of the admissions committee.

[Amnion and ocular surface problems]. / Amnios et problèmes de surface oculaire.

The amniotic membrane, the most internal placental membrane, has various properties useful in ophthalmology. Collected on delivery by elective Caesarean section, the amnion is prepared under sterile conditions, and, usually, cryopreserved until its use as a biological bandage or as a substrate for epithelial growth in the management of various ocular surface conditions. Specifically, the amnion is used to : (1) limit formation of adhesive bands between eyelids and eyeball (symblepharon) or the progression of a fibrovascular outgrowth towards the cornea (pterygium) or to (2) facilitate the healing of corneal ulcers, bullous keratopathy, and corneal stem cell deficiency. In this last condition, either hereditary or acquired after a thermal or a chemical burn, corneal stem cells, located at a transitional zone between the cornea and conjunctiva, are lost. These cells are essential for renewal of corneal epithelium in normal and in diseased states. The loss of these cells leaves the corneal surface free for invasion by conjunctival epithelium. Not only, does conjunctival epithelium support the development of vascularisation on the normally avascular cornea, but some conjunctival cells differentiate into mucus secreting goblet cells. Such a change in phenotype leads to loss of corneal transparency and visual disability. The removal of this fibro-vascular outgrowth in combination with transplantation of both amniotic membrane and corneal stem cells are used to treat this condition. The amnion stimulates the proliferation of less differentiated cells which have the potential to reconstruct the cornea. This potential is at the origin of the hypothesis that the amnion may provide an alternative niche for limbal stem cells of the corneal epithelium. It abounds in cytokines and has antalgic, anti-bacterial, anti-inflammatory and anti-immunogenic properties, in addition to allowing, like fetal skin does, wound healing with minimal scar formation. These desirable properties are responsible for the increasing use of amniotic membrane in ophthalmology. The complete understanding of the mechanisms of action of amniotic membrane for ocular surface diseases has yet to be understood. Once revealed by research, they may provide new pharmacological avenues to treat ocular surface diseases.

Advances in the use of adhesives in ophthalmology.

PURPOSE OF REVIEW: To summarize the known uses of available medical tissue adhesives in the management of diseases of the anterior segment, highlighting recent developments in the field. RECENT FINDINGS: Human fibrin glues may be used in place of cyanoacrylate tissue adhesives in the treatment of progressive corneal thinning and small perforations, potentially resulting in less corneal and conjunctival inflammatory reaction. Additional currently proposed uses of fibrin glues in ophthalmic surgery include minimizing sutures in recurrent pterygium surgery, forniceal reconstruction, amniotic membrane transplantation, and lamellar corneal grafting. SUMMARY: After reviewing the literature pertaining to the current use of tissue adhesives in ophthalmic surgery, the authors conclude that the main indication for cyanoacrylate tissue adhesives is for the treatment of progressive corneal thinning and small, uncomplicated corneal perforations. Human fibrin glues appear to be equally effective in such cases and have the advantage of biocompatibility, allowing application over a larger surface area and the use of a superficial covering layer such as amniotic membrane or conjunctiva for further reinforcement and promotion of rapid re-epithelialization. Other applications of human fibrin glues in ophthalmic surgery are evolving, but their widespread use is limited by concern over the theoretic risk of viral transmission and the complexity of their preparation and application in comparison with traditional sutures.

Bilateral corneal ring opacity of unknown origin.

PURPOSE: To report one case of a bilateral ring-shaped opacity in the mid-peripheral corneal stroma of unknown origin. METHODS: Case report. RESULTS: The authors describe the clinical history and ocular examination of an asymptomatic 82-year-old woman with a bilateral ring-shaped opacity located in the corneal stroma. This rare corneal anomaly was discovered by chance, and the etiology is unknown. CONCLUSION: An unusual bilateral corneal abnormality is reported.

The VF-14 index of visual function in recipients of a corneal graft: a 2-year follow-up study.

PURPOSE: To assess visual functioning and other health-related quality of life outcomes after corneal grafting. DESIGN: A cohort study of corneal graft recipients observed for a minimum of 2 years after transplantation. METHODS: Repeated measurements were obtained by telephone interviews preoperatively and later at 1 and 2 years post-corneal transplantation in 217 patients with the following questionnaires: visual function index (VF-14), visual symptom score and global measures of trouble with vision, dissatisfaction with vision, ocular pain, and discomfort. Demographic, past ocular history, repeated best-corrected visual acuity (BCVA), and detailed eye examination data were also collected. RESULTS: Grafted eyes gained a mean of more than four lines of vision on the Early Treatment Diabetic Retinopathy Study (ETDRS) chart 1 year after transplantation. The mean visual function index (VF-14) score improved from 68% +/- 26% preoperatively to 81% +/- 21% at 1 year. Average visual acuity (VA) and VF-14 values were unchanged at 2 years. The activities of daily living that showed the largest and most significant improvement were reading small print, driving in daytime, and watching television. A number of subjects (9%) presented with a maximum VF-14 score preoperatively, leaving no room for improvement with this outcome index. The VF-14 was especially responsive for corneal graft candidates with low levels of vision before surgery. Blurry vision, pain and discomfort scores, and the global measures of trouble and dissatisfaction with vision also improved after corneal grafting. CONCLUSION: The VF-14 index of functional visual impairment is a responsive and useful outcome index in recipients of a corneal graft.