Quality of life of low vision patients: a systematic review and meta-analysis.

OBJECTIVE: Quality of vision plays an important role in everyday living, and low vision (LV) can take a toll on individual's quality of life (QOL). The objective of this paper is to evaluate the impact of LV on QOL and depressive symptoms in LV patients compared with healthy controls. DESIGN: Systematic review and meta-analysis. METHODS: Literature was systematically searched to obtain all relevant records. Covidence software was used to conduct the systematic review. Duplicate records were removed, and 2 independent reviewers screened records for relevance. After screening, risk of bias assessment was carried out. Data were extracted and meta-analysis was performed using STATA 15.0. Fixed-effect and random-effect models were computed based on heterogeneity. RESULTS: In total, 2870 records were retrieved from database and grey literature searches. Twelve articles (35 341 subjects) were included for quantitative analysis. Overall, the QOL of LV patients was significantly lower compared with healthy individuals. Common QOL questionnaires, including 25-item visual function questionnaire (VFQ-25) (standard mean difference [SMD] = 0.91, confidence interval [CI]: [0.42-1.40]), 36-item short form survey (SMD = 0.53, CI: [0.26-0.80]), VFQ-14 (SMD = 0.58, CI: [0.42-0.74]), and visual function QOL questionnaire (SMD = 0.68, CI: [0.54-0.82]), demonstrated a poor QOL in LV patients compared with healthy controls. Additionally, odds of depressive symptoms were significantly greater (odds ratio = 2.25, CI: [1.58-3.21]) in LV patients compared with controls. CONCLUSION: LV patients demonstrated a poor QOL and higher odds of depressive symptoms compared with healthy controls.

Trends in low vision care provided by ophthalmologists in Ontario between 2009 and 2015.

OBJECTIVE: Little is known about how low vision services by ophthalmologists are being provided. Here, we analyze the patterns of provision and utilization of vision rehabilitation services in Ontario, Canada. DESIGN: Retrospective population-based study between 2009 and 2015. PARTICIPANTS: Ophthalmologists (n = 92) who billed for vision rehabilitation services through the Ontario Health Insurance Plan in Ontario and the patients (n = 8949) who received these services. METHODS: Billing data for low vision services (2009-2015) was received from Ontario Health Insurance Plan. Data were analyzed to describe patient demographics (age, sex, geographic distribution, number, and type of visits) and service provider information (geographic location, number of years providing services, and number of services per year). RESULTS: It is estimated that ≤ 5% of patients with low vision in Ontario accessed these vision rehabilitation services by ophthalmologists. The majority of these patients were females (61%) and > 60 years old (79%). While patient and provider geographic distributions overlapped in the areas with largest patient populations, many regions lacked services. The majority of patients (71%) made only one vision rehabilitation visit. Nine providers practiced low vision for 7 years, while 43 provided services for only 1 year. In 2015, the most common diagnostic service provided to low vision patients was Optical Coherence Tomography of the retina and the most common therapeutic service was intravitreal for wet age-related macular degeneration. CONCLUSION: Although low vision services increased between 2009 and 2015, there were differences in ability to access care based on age, sex, and geographic location.

Clinical effectiveness of currently available low-vision devices in glaucoma patients with moderate-to-severe vision loss.

PURPOSE: The aim of this trial is to study the effectiveness of currently available low-vision devices in glaucoma patients with moderate-to-severe vision loss. DESIGN: This is a randomized pilot clinical trial. PARTICIPANTS: Sixteen low-vision glaucoma patients participated in this study. METHODS: Patients with a best-corrected visual acuity between 20/70 and 20/400 in the better eye and a diagnosis of stable primary or secondary open-angle glaucoma were randomized to a low-vision treatment group or a nonintervention control group. A telephone interview was conducted before and after the 4-week testing period to assess functional vision. Patients placed in the treatment group received a low-vision examination and used various currently available low-vision aids. Patients placed in the control group received a low-vision examination only. Changes in patients' reading ability and overall visual ability were chosen as the primary outcomes. Other visual functioning domains (mobility, visual information processing and visual motor skills) were considered as secondary outcomes. RESULTS: Ten patients in the treatment group showed a significant improvement in reading ability and overall visual ability compared to the control group. The difference in mean score for reading ability was 2.52 logits (2.02; P<0.05) and overall visual ability was 0.78 logits (0.64; P<0.05). However, no significant improvement was noted in the other visual functioning domains involving mobility and visual motor skills. CONCLUSION: Currently available low-vision devices primarily enhance central vision with limited benefits to functional activities relying on peripheral vision.

Correction: Summary of Glaucoma Diagnostic Testing Accuracy: An Evidence-Based Meta-Analysis.

[This corrects the article DOI: 10.14740/jocmr2643w.].

Summary of Glaucoma Diagnostic Testing Accuracy: An Evidence-Based Meta-Analysis.

BACKGROUND: New glaucoma diagnostic technologies are penetrating clinical care and are changing rapidly. Having a systematic review of these technologies will help clinicians and decision makers and help identify gaps that need to be addressed. This systematic review studied five glaucoma technologies compared to the gold standard of white on white perimetry for glaucoma detection. METHODS: OVID(®) interface: MEDLINE(®) (In-Process & Other Non-Indexed Citations), EMBASE(®), BIOSIS Previews(®), CINAHL(®), PubMed, and the Cochrane Library were searched. A gray literature search was also performed. A technical expert panel, information specialists, systematic review method experts and biostatisticians were used. A PRISMA flow diagram was created and a random effect meta-analysis was performed. RESULTS: A total of 2,474 articles were screened. The greatest accuracy was found with frequency doubling technology (FDT) (diagnostic odds ratio (DOR): 57.7) followed by blue on yellow perimetry (DOR: 46.7), optical coherence tomography (OCT) (DOR: 41.8), GDx (DOR: 32.4) and Heidelberg retina tomography (HRT) (DOR: 17.8). Of greatest concern is that tests for heterogeneity were all above 50%, indicating that cutoffs used in these newer technologies were all very varied and not uniform across studies. CONCLUSIONS: Glaucoma content experts need to establish uniform cutoffs for these newer technologies, so that studies that compare these technologies can be interpreted more uniformly. Nevertheless, synthesized data at this time demonstrate that amongst the newest technologies, OCT has the highest glaucoma diagnostic accuracy followed by GDx and then HRT.

RETROSPECTIVE REVIEW OF LUCENTIS "TREAT AND EXTEND" PATTERNS AND OUTCOMES IN AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To assess patterns and outcomes of a "Treat and Extend" dosing regimen of ranibizumab in patients with age-related macular degeneration. METHODS: Three hundred and thirty two treatment-naive age-related macular degeneration patients starting therapy with ranibizumab between January 1, 2011, and June 30, 2012, at the Ivey Eye Institute were reviewed, and 79 met inclusion criteria. Patients on Treat and Extend dosing regimen underwent an induction phase with monthly injections and then moved onto an extension phase. Change in visual acuity and central retinal thickness during the induction and extension phases were recorded. RESULTS: During the induction phase, patients had a significant gain in vision and decrease in central retinal thickness (+8.4 letters, P < 0.001 and -81.3 µm, P < 0.001). During the extension phase, patients did not have significant change in vision (-0.5 letters, P = 0.81) and did not have significant change in central retinal thickness (-11.5 µm, P = 0.17). The average extension interval between treatments was 47.7 days, with patients receiving an average of 8.6 injections per year. Cost analysis showed it cost US $16,659 to treat 1 patient in the first year on Treat and Extend dosing regimen compared with US $20,614 on monthly dosing. CONCLUSION: Treat and Extend dosing regimen allows similar visual outcomes to monthly dosing, while reducing the total number of injections, visits, and overall cost.

Preoperative Factors Affecting Stereopsis after Surgical Alignment of Acquired Partially Accommodative Esotropia.

BACKGROUND/AIM: Despite successful ocular realignment, many strabismus patients never develop high levels of stereopsis. The purpose of this study was to determine preoperative factors that affect postoperative stereopsis in patients with acquired partially accommodative esotropia (APAET). METHODS: This was a retrospective chart review of patients who underwent successful surgery for APAET. We compared preoperative factors between patients achieving postoperative stereopsis of 100 seconds of arc or better versus those with worse than 100 seconds of arc. RESULTS: Fifty-seven patients met our inclusion criteria. Twenty-four (42%) had a final stereopsis of 100 seconds of arc or better. The mean age of onset of esodeviation for patients attaining stereopsis of 100 seconds of arc or better was 31.8 ± 12.9 months, versus 23.9 ± 10.0 months (p = 0.012) for patients with worse than 100 seconds of arc. Duration of constant misalignment was not significantly different between the two groups (30.1 ± 18.5 for patients attaining 100 seconds of arc versus 27.3 ± 18.6 months; p = 0.57). A multivariate regression analysis found older age of onset to be the only predictive factor for achieving better postoperative stereopsis (odds ratio 1.065, 95% CI: 1.014-1.118). CONCLUSION: Age of onset appears to be the most important factor affecting postoperative stereopsis in patients with APAET. Patients with an age of onset after 36 months tended to have better outcomes regardless of the duration of misalignment. Duration of misalignment and age at surgery did not have a significant impact on postoperative stereopsis in our patient population.

Intravitreal ranibizumab for the treatment of fibrovascular pigment epithelial detachment in age-related macular degeneration.

OBJECTIVE: To determine the response of predominantly fibrovascular pigment epithelial detachments (PED)-type lesions (secondary to age-related macular degeneration [AMD]) to intravitreal ranibizumab. DESIGN: This was an open-label prospective study. PARTICIPANTS: Thirty-two patients with predominantly fibrovascular PED-type lesions secondary to AMD were included in this study. Three patients were excluded from the final analysis. METHODS: Patients received monthly intravitreal ranibizumab injections for 6 months (induction). At 6 months, patients not experiencing a visual improvement from baseline Early Treatment of Diabetic Retinopathy Study (ETDRS) visual acuity or not showing a reduction in PED height (based on optical coherence tomography [OCT]) were deemed ranibizumab nonresponders and received no further injections but underwent re-evaluation at 12 months. Patients deemed responders continued with OCT-guided active treatment on an as-needed basis for an additional 6 months. RESULTS: Twenty-four patients (82.8%) were ranibizumab responders and 5 were (17.2%) nonresponders. For ranibizumab responders, mean ETDRS visual acuity improved by 7.2 ± 9.8 letters at 6 months (p = 0.002) and 6.3 ± 8.6 letters at 12 months (p = 0.002). Ranibizumab nonresponders experienced a decline in mean visual acuity of 8.2 ± 4.6 letters at 6 months (p = 0.02) and 18.2 ± 10.11 letters at 12 months (p = 0.02). At baseline, responders had a mean PED height of 345.8 ± 96.0 µm, which decreased to 111.6 ± 133.2 µm at 6 months (p < 0.001) and had a slight increase at 12 months to 144.8 ± 146.3 µm (p < 0.001). Two responders (8.3%) and 2 nonresponders (40%) developed retinal pigment epithelium tears while on treatment. CONCLUSIONS: Intravitreal ranibizumab appears to be a well-tolerated treatment option for patients with fibrovascular PED. Further large-scale, prospective studies may assist in delineating the best treatment protocol.

Immediately sequential bilateral cataract surgery: a cost-effective procedure.

OBJECTIVE: The objective of this project was to perform a cost-effectiveness analysis (CEA) of immediately sequential bilateral cataract surgery (ISBCS) versus delayed sequential bilateral cataract surgery (DSBCS) to determine whether ISBCS represents an appropriate, cost-effective way to rapidly rehabilitate a patient's visual impairment. DESIGN: A systematic review followed by a primary economic analysis with computer-based econometric modeling. PARTICIPANTS: Not applicable. METHODS: We constructed a decision analytic model from the perspective of the public third-party payer (i.e., the Ministry of Health) to conduct a CEA of both surgeries, ISBCS and DSBCS. Cost data consisted of the costs of the surgery, intravitreal injections, medications, and drops, all of which were obtained from a comprehensive literature search and from records at St. Joseph's Hospital, London, Ont. The effectiveness was measured by the utility values associated with visual acuity in the better seeing eye. RESULTS: ISBCS resulted in an incremental effectiveness of 0.08 utility at an incremental cost of $1607. Discounting the quality-adjusted life-years (QALYs) gained by an annual interest rate of 3% resulted in 0.932 QALYs gained. The cost-effectiveness of ISBCS was calculated to be $1431 per QALY gained. A 1-way sensitivity analysis was performed by varying costs, utility values, probabilities, and discounting rates. This analysis varied the incremental cost-effectiveness ratio but did not change the conclusion. CONCLUSIONS: Health economics assessment showed that, compared with DSBCS, ISBCS is a cost-effective procedure. This finding will be highly useful to policy-makers, decision-makers, clinicians, hospital administrators, and payers in making cost-efficient decisions.

Factors affecting postoperative stereopsis in acquired nonaccommodative esotropia.

OBJECTIVE: To identify and examine factors that affect postoperative binocularity in children diagnosed with acquired nonaccommodative esotropia (ANAET). DESIGN: Retrospective chart review. PARTICIPANTS: Thirty-four pediatric patients who received surgery for ANAET by 1 surgeon (I.M.) at the Ivey Eye Institute, University of Western Ontario (London, Ont.). METHODS: A multivariate logistic regression analysis was performed to evaluate the effect of the following factors on achieving stereopsis postoperatively: age at onset of esotropia (AO), duration of misalignment (DOM), presence of A/V pattern, recent intermittency of esotropia, and presence of dense amblyopia. RESULTS: Forty-one percent of all patients achieved stereoacuity of 100 seconds of arc or better. AO was found to be the only factor significantly associated with postoperative stereopsis (adjusted odds ratio = 1.063, P<0.05). None of the children with AO who were younger than 30 months regained bifoveal fixation regardless of their DOM. CONCLUSIONS: Age of onset appears to play a crucial role on postoperative functional outcome in children with ANAET. Delayed surgery in children with an age of onset beyond 30 months did not seem to be detrimental to regaining bifoveal fixation.

Comparison of outcomes after switching treatment from intravitreal bevacizumab to ranibizumab in neovascular age-related macular degeneration.

OBJECTIVE: To compare visual acuity and central retinal thickness in patients initially treated with bevacizumab (Avastin) and switched to ranibizumab (Lucentis) for neovascular age-related macular degeneration (AMD). DESIGN: A retrospective chart review. PARTICIPANTS: This study included 87 eyes from 80 patients over the age of 65 with neovascular AMD. METHODS: Patients were initially treated with bevacizumab injections every 6 weeks and then switched to ranibizumab every 4 weeks when it became publicly funded by the Ontario government. Outcomes include comparison of visual acuity and central retinal thickness after bevacizumab treatment, and after switching to ranibizumab. RESULTS: Visual acuity improved significantly versus initial baseline values following a treatment course of 3 or more injections of bevacizumab (0.58 logMar, SD = 0.30 vs 0.73 logMar, SD = 0.41; p = 0.0007). Patients then showed a further significant improvement in visual acuity after switching and receiving a course of ranibizumab (0.51 logMar, SD = 0.32) (p = 0.0122). Mean central retinal thickness as measured by optical coherence tomography significantly decreased after a course of bevacizumab (p = 0.0158), and a further decrease was noted after a subsequent course of ranibizumab (p < 0.0001). CONCLUSIONS: There was a significant improvement in visual acuity and central retinal thickness in patients with neovascular AMD initially treated with bevacizumab. When these patients were uniformly switched to ranibizumab there was a further significant improvement in visual acuity and a reduction of retinal thickness. It appears that ranibizumab can maintain, or improve the effect achieved after an initial course of bevacizumab.

Clinical effects of three types of silicone intubations in repairing lacerations of canaliculus.

OBJECTIVE: To evaluate the clinical effects of one-passage, double-passage and circular canalicular intubations in repairing lacerations of canaliculus. METHODS: A total of 109 eyes in 109 cases of canalicular laceration were repaired with three types of silicone intubations, among which 23 with one-passage canalicular intubation, 51 with double-passage canalicular intubation, and 35 with circular canalicular intubation. The average follow-up period was 12-15 months. RESULTS: The wound/junction of the lacrimal canaliculi was ruptured in 5 cases (9.80%) of the double-passage group, 3 cases (8.57%) of the circular group, and 8 cases (34.78%) of the one-passage group. The rupture incidence of the one-passage group was significantly higher than that of the other two groups (X(2) equal to 9.416, P less than 0.01). During the intubation, canaliculitis was observed in 12 cases (23.53%) of the double-passage group, while only 3 cases (8.57%) in the circular group and 8 cases (34.78%) in the one-passage group. The circular group had significantly lower incidence of canaliculitis than the other two groups (X(2) equal to 6.095, P less than 0.05). After extubation 6 months after laceration repair, the lacrimal passage remained patent with canalicular irrigation in 46 cases (90.20%) in the double-passage group, 30 cases (85.71%) in the circular group and 15 cases (65.22%) in the one-passage group. Six months after surgery, the canalicular patency in the one-passage group was significantly lower than that of the other two groups (X(2) equal to 7.390, P less than 0.05). CONCLUSIONS: Circular canalicular intubation is more stable and has less surgical complications than the double-passage and one-passage canalicular intubations. It is also more effective clinically 12-15 months after laceration surgery.

Triamcinolone acetonide as adjunctive treatment to verteporfin in neovascular age-related macular degeneration: a prospective randomized trial.

PURPOSE: To examine the use of intravitreal triamcinolone acetonide (IVTA) as adjunctive therapy to photodynamic therapy (PDT) in the treatment of occult and minimally classic choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). DESIGN: Single-center prospective randomized pilot clinical trial. PARTICIPANTS: Thirty eyes of 30 patients with occult or minimally classic CNV secondary to AMD. METHODS: Patients were randomized prospectively to receive either PDT alone or combined PDT plus IVTA treatment for CNV secondary to AMD. Standard verteporfin PDT was performed in all patients. In the PDT plus IVTA group, a 12-mg intravitreal injection of triamcinolone acetonide was given 30 minutes after PDT. Active lesions were retreated every 3 months for 1 year. MAIN OUTCOME MEASURES: Change in visual acuity and retreatment rate. RESULTS: Mean visual acuity remained stable in the PDT plus IVTA group (-1.9 Early Treatment Diabetic Retinopathy Study [ETDRS] letters; P = 0.58), but declined significantly in the PDT alone group (-13.3 ETDRS letters; P = 0.02). The treatment rate was 1.13 in the PDT plus IVTA group and 3.6 in the PDT alone group (P<0.0001). Mean contrast sensitivity increased by 3.6 letters (P = 0.09) in the PDT plus IVTA group and decreased by -1.84 letters (P = 0.07) in the PDT alone group. Cataract progression was noted in 4 of 7 phakic eyes in the PDT plus IVTA group. Six patients (40%) in the combined PDT plus IVTA group required topical glaucoma therapy for control of elevated intraocular pressure. CONCLUSIONS: This pilot study demonstrated effective stabilization of visual acuity and reduced treatment frequency at 12 months with combination PDT plus IVTA therapy versus PDT alone. Larger randomized trials are ongoing to determine the efficacy and risks of PDT with IVTA.