The Evolution of the American Board of Ophthalmology Written Qualifying Examination.

Since the inception of board certification in ophthalmology in 1916, a written assessment of candidates' knowledge base has been an integral part of the certification process. Although the committee structure and technique for writing examination questions has evolved over the past 100 years, the written qualifying examination remains an essential tool for assessing the competency of physicians entering the workforce. To develop a fair and valid examination, the American Board of Ophthalmology builds examination questions using evidence-based, peer-reviewed literature and adheres to accepted psychometric assessment standards.

Low vision depression prevention trial in age-related macular degeneration: a randomized clinical trial.

PURPOSE: To compare the efficacy of behavior activation (BA) + low vision rehabilitation (LVR) with supportive therapy (ST) + LVR to prevent depressive disorders in patients with age-related macular degeneration (AMD). DESIGN: Single-masked, attention-controlled, randomized, clinical trial with outcome assessment at 4 months. PARTICIPANTS: Patients with AMD and subsyndromal depressive symptoms attending retina practices (n = 188). INTERVENTIONS: Before randomization, all subjects had 2 outpatient LVR visits, and were then randomized to in-home BA+LVR or ST+LVR. Behavior activation is a structured behavioral treatment that aims to increase adaptive behaviors and achieve valued goals. Supportive therapy is a nondirective, psychological treatment that provides emotional support and controls for attention. MAIN OUTCOME MEASURES: The Diagnostic and Statistical Manual IV defined depressive disorder based on the Patient Health Questionnaire-9 (primary outcome), Activities Inventory, National Eye Institute Vision Function Questionnaire-25 plus Supplement (NEI-VFQ), and NEI-VFQ quality of life (secondary outcomes). RESULTS: At 4 months, 11 BA+LVR subjects (12.6%) and 18 ST+LVR subjects (23.4%) developed a depressive disorder (relative risk [RR], 0.54; 95% CI, 0.27-1.06; P = 0.067). In planned adjusted analyses the RR was 0.51 (95% CI, 0.27-0.98; P = 0.04). A mediational analysis suggested that BA+LVR prevented depression to the extent that it enabled subjects to remain socially engaged. In addition, BA+LVR was associated with greater improvements in functional vision than ST+LVR, although there was no significant between-group difference. There was no significant change or between-group difference in quality of life. CONCLUSIONS: An integrated mental health and low vision intervention halved the incidence of depressive disorders relative to standard outpatient LVR in patients with AMD. As the population ages, the number of persons with AMD and the adverse effects of comorbid depression will increase. Promoting interactions between ophthalmology, optometry, rehabilitation, psychiatry, and behavioral psychology may prevent depression in this population.

Improving function in age-related macular degeneration: a randomized clinical trial.

PURPOSE: To compare the efficacy of problem-solving therapy (PST) with supportive therapy (ST) to improve targeted vision function (TVF) in age-related macular degeneration (AMD). DESIGN: Single-masked, attention-controlled, randomized clinical trial with outcome assessments at 3 months (main trial endpoint) and 6 months (maintenance effects). PARTICIPANTS: Patients with AMD (n = 241) attending retina practices. INTERVENTIONS: Whereas PST uses a structured problem-solving approach to reduce vision-related task difficulty, ST is a standardized attention-control treatment. MAIN OUTCOME MEASURES: We assessed TVF, the 25-item National Eye Institute Vision Function Questionnaire plus Supplement (NEI VFQ), the Activities Inventory (AI), and vision-related quality of life (QoL). RESULTS: There were no between-group differences in TVF scores at 3 (P = 0.47) or 6 (P = 0.62) months. For PST subjects, mean ± standard deviation TVF scores improved from 2.71±0.52 at baseline to 2.18±0.88 at 3 months (P = 0.001) and were 2.18±0.95 at 6 months (change from 3 to 6 months, P = 0.74). For ST subjects, TVF scores improved from 2.73±0.52 at baseline to 2.14±0.96 at 3 months (P = 0.001) and were 2.15±0.96 at 6 months (change from 3 to 6 months, P = 0.85). Similar proportions of PST and ST subjects had less difficulty performing a TVF goal at 3 months (77.4% vs 78.6%, respectively; P = 0.83) and 6 months (76.2% vs 79.1%, respectively; P = 0.61). There were no changes in the NEI VFQ or AI. Vision-related QoL improved for PST relative to ST subjects at 3 months (F(4, 192) = 2.46; P = 0.05) and at 6 months (F(4, 178) = 2.55; P = 0.05). The PST subjects also developed more adaptive coping strategies than ST subjects. CONCLUSIONS: We found that PST was not superior to ST at improving vision function in patients with AMD, but that PST improved their vision-related QoL. Despite the benefits of anti-vascular endothelial growth factor treatments, AMD remains associated with disability, depression, and diminished QoL. This clinical reality necessitates new rehabilitative interventions to improve the vision function and QoL of older persons with AMD. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Psychological and cognitive determinants of vision function in age-related macular degeneration.

OBJECTIVE: To investigate the effect of coping strategies, depression, physical health, and cognition on National Eye Institute Visual Function Questionnaire scores obtained at baseline in a sample of older patients with age-related macular degeneration (AMD) enrolled in the Improving Function in AMD Trial, a randomized controlled clinical trial that compares the efficacy of problem-solving therapy with that of supportive therapy to improve vision function in patients with AMD. METHODS: Baseline evaluation of 241 older outpatients with advanced AMD who were enrolled in a clinical trial testing the efficacy of a behavioral intervention to improve vision function. Vision function was characterized as an interval-scaled, latent variable of visual ability based on the near-vision subscale of the National Eye Institute Vision Function Questionnaire-25 plus Supplement. RESULTS: Visual ability was highly correlated with visual acuity. However, a multivariate model revealed that patient coping strategies and cognitive function contributed to their ability to perform near-vision activities independent of visual acuity. CONCLUSIONS: Patients with AMD vary in their coping strategies and cognitive function and in their visual acuity, and that variability determines patients' self-report of vision function. Understanding patient coping mechanisms and cognition may help increase the precision of vision rating scales and suggest new interventions to improve vision function and quality of life in patients with AMD. Trial Registration  clinicaltrials.gov Identifier: NCT00572039.

Improving function in age-related macular degeneration: design and methods of a randomized clinical trial.

Age-Related Macular Degeneration (AMD) is the leading cause of severe vision loss in older adults and impairs the ability to read, drive, and live independently and increases the risk for depression, falls, and earlier mortality. Although new medical treatments have improved AMD's prognosis, vision-related disability remains a major public health problem. Improving Function in AMD (IF-AMD) is a two-group randomized, parallel design, controlled clinical trial that compares the efficacy of Problem-Solving Therapy (PST) with Supportive Therapy (ST) (an attention control treatment) to improve vision function in 240 patients with AMD. PST and ST therapists deliver 6 one-hour respective treatment sessions to subjects in their homes over 2 months. Outcomes are assessed masked to treatment assignment at 3 months (main trial endpoint) and 6 months (maintenance effects). The primary outcome is targeted vision function (TVF), which refers to specific vision-dependent functional goals that subjects highly value but find difficult to achieve. TVF is an innovative outcome measure in that it is targeted and tailored to individual subjects yet is measured in a standardized way. This paper describes the research methods, theoretical and clinical aspects of the study treatments, and the measures used to evaluate functional and psychiatric outcomes in this population.

Activity loss is associated with cognitive decline in age-related macular degeneration.

BACKGROUND/METHODS: The objective of this study was to determine whether relinquishing cognitive, physical, and social activities is associated with an increased risk of cognitive decline in patients with age-related macular degeneration (AMD). We conducted a 3-year longitudinal study of 206 nondemented patients with AMD. RESULTS: Twenty-three subjects (14.4%) declined cognitively. Age, sex, education, decline in visual acuity, and number of dropped activities were associated with cognitive decline; each additional dropped activity increased the risk by 58%. Subjects who relinquished three activities were 3.87 times (95% confidence interval, 1.95-7.76) more likely to become demented than subjects who relinquished no activities; those who relinquished five activities were 9.54 times (95% confidence interval, 3.05-30.43) more likely. A multivariate model demonstrated that number of dropped activities was a powerful predictor of cognitive decline after controlling for relevant risk factors, particularly for subjects younger than 80 years of age. CONCLUSIONS: Relinquishing valued activities is associated with an increased risk of cognitive decline in older patients with vision loss caused by AMD. These data suggest the importance of promoting optimal cognitive and physical health in patients with AMD and perhaps other chronic diseases.

Preventing depression in age-related macular degeneration.

CONTEXT: Age-related macular degeneration is a prevalent disease of aging that may cause irreversible vision loss, disability, and depression. The latter is rarely recognized or treated in ophthalmologic settings. OBJECTIVE: To determine whether problem-solving treatment can prevent depressive disorders in patients with recent vision loss. DESIGN: Randomized, controlled trial. SETTING: Outpatient ophthalmology offices in Philadelphia, Pennsylvania. PATIENTS: Two hundred six patients aged 65 years or older with recent diagnoses of neovascular age-related macular degeneration in one eye and pre-existing age-related macular degeneration in the fellow eye. INTERVENTION: Patients were randomly assigned to problem-solving treatment (n = 105) or usual care (n = 101). Problem-solving treatment therapists delivered 6 sessions during 8 weeks in subjects' homes. MAIN OUTCOME MEASURES: Outcomes were assessed at 2 months for short-term effects and 6 months for maintenance effects. These included DSM-IV-defined diagnoses of depressive disorders, National Eye Institute Vision Function Questionnaire-17 scores, and rates of relinquishing valued activities. RESULTS: The 2-month incidence rate of depressive disorders in problem-solving-treated subjects was significantly lower than controls (11.6% vs 23.2%, respectively; odds ratio, 0.39; 95% confidence interval, 0.17-0.92; P = .03). Problem-solving treatment also reduced the odds of relinquishing a valued activity (odds ratio, 0.48; 95% confidence interval, 0.25-0.96; P = .04). This effect mediated the relationship between treatment group and depression. By 6 months, most earlier observed benefits had diminished, though problem-solving treatment subjects were less likely to suffer persistent depression (chi2(1,3) = 8.46; P = .04). CONCLUSIONS: Problem-solving treatment prevented depressive disorders and loss of valued activities in patients with age-related macular degeneration as a short-term treatment, but these benefits were not maintained over time. Booster or rescue treatments may be necessary to sustain problem-solving treatment's preventative effect. This study adds important new information to the emerging field of enhanced-care models to prevent or treat depression in older persons. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00042211.

Dissatisfaction with performance of valued activities predicts depression in age-related macular degeneration.

OBJECTIVE: To determine whether dissatisfaction with performance of valued activities predicts depression in patients with age-related macular degeneration (AMD). PATIENTS: Two hundred and six patients with newly diagnosed neovascular AMD in one eye and pre-existing AMD in the fellow eye who were participating in a clinical trial of a psychosocial intervention to prevent depression. MEASURES: Structured clinical evaluations of vision function, depression, visual acuity, contrast sensitivity and medical morbidity. Subjects were classified as dissatisfied if they indicated that they were dissatisfied with their performance of a valued activity. RESULTS: Subjects who were dissatisfied with performance of valued activities (n = 71) had similar demographic characteristics to satisfied subjects (n = 135) but had worse visual acuity (p < 0.054), greater medical comorbidity (p < 0.006), and lower vision function (p < 0.001). Dissatisfied subjects were almost 2.5 times more likely (OR = 2.41; [95% CI 1.02, 5.65]; p = 0.044) to become depressed within 2 months than satisfied subjects independent of baseline visual acuity, vision function, and medical comorbidity. CONCLUSION: Dissatisfaction with performance of valued activities in older persons with AMD predicts depression over a 2-month period. Assessing the ability to pursue valued activities may identify patients at risk for depression and prompt clinicians to initiate rehabilitative interventions and careful surveillance for depression.

Minimal depression and vision function in age-related macular degeneration.

OBJECTIVE: To evaluate the impact of minimal depression on subjective and objective vision function measures in age-related macular degeneration (AMD). DESIGN: Prospective cross-sectional study. PARTICIPANTS: Two hundred six outpatients with newly diagnosed neovascular AMD in one eye and preexisting AMD in the fellow eye. METHODS: Structured clinical evaluations of visual acuity (VA), contrast sensitivity, vision function, and depression. MAIN OUTCOME MEASURES: The 17-item National Eye Institute Visual Function Questionnaire (NEI VFQ 17), Melbourne Low-Vision Index (MLVI), Chronic Disease Score, and Hamilton Depression Rating Scale. RESULTS: Minimally depressed subjects had significantly worse vision function on both the NEI VFQ 17 and performance-based tasks of the MLVI than nondepressed subjects, independent of severity of VA, contrast sensitivity, and medical status. CONCLUSIONS: Minimally depressed patients with AMD, who would not be considered depressed according to current diagnostic standards, suffer decrements in vision function that cannot be accounted for by the severity of their eye disease or general medical problems. These data emphasize the need to assess depressive symptoms in research studies that use vision function outcome measures and in clinical practice to identify excess vision-related disability in patients with AMD.

Coats disease: a lifetime disease.

PURPOSE: To document the recurrent nature of Coats Disease. METHODS: This study is a retrospective chart review approved by our Institutional Review Board. Thirteen patients (13 eyes) were diagnosed with Coats Disease starting in 1966. Age, visual acuity, time of onset, method of treatment, and the number and intervals of recurrences were documented. Recurrences were recorded once initial treatment proved successful and most exudates had absorbed. The length of follow-up for each patient and the most recent visual acuity was recorded. RESULTS: The average follow-up period for the 13 patients was 12.4 years with a range from 4.0 to 37.5 years. Eleven patients (85%) were male, two (15%) were female and all had unilateral involvement. The average age at diagnosis was 7.0 years with a range from 9 months to 27 years. Four out of the twelve treated patients (33%) had recurrences, and three of the four had multiple recurrences. The average elapsed time from successful treatment to the first recurrence was 4.3 years with a range from 3.3 to 5.4 years. The average number of recurrences was 3.3. CONCLUSION: Coats Disease can recur so it is important that parents educate any affected children regarding the necessity of follow-up, including throughout their adult years.

Retinopathy of prematurity: late complications in the baby boomer generation (1946-1964).

PURPOSE: To report the natural history and late complications of retinopathy of prematurity (ROP) in members of the baby boomer generation (1946-1964). METHODS: Retrospective observational series of 86 eyes from 47 adult ROP patients (aged 45 to 56 years) who did not receive treatment as infants. Posterior segment pathology, refractive status, lens status, and visual acuity were evaluated. RESULTS: Seventy-six eyes (88.4%) had posterior segment pathology due to ROP, including 22 (25.6%) with retinal detachments. The rates of myopia and cataract formation were 90.7% and 83.7%, respectively. Visual acuity was 20/200 or worse in 43 eyes (51.2%) and 20/60 or better in 35 (41.7%). CONCLUSIONS: There are significant late complications of ROP underscoring the importance of lifelong follow-up.

Effect of depression on vision function in age-related macular degeneration.

OBJECTIVES: To report the prevalence rate of depression in older patients with recent vision loss due to age-related macular degeneration (AMD) and to describe the effect of depression on self-reported vision function during 6 months. METHODS: Prospective cohort study of 51 older patients with recent-onset bilateral AMD attending the Retina Clinic of Wills Eye Hospital, Philadelphia, Pa. Main outcome measures included the Center for Epidemiological Studies Depression Scale, visual acuity, Functional Vision Screening Questionnaire, Chronic Disease Score, and Community Disability Scale. RESULTS: Seventeen patients (33%) were depressed at baseline and had worse visual acuity (P =.04) and greater levels of vision-specific (P =.03) and general (P =.002) physical disability than nondepressed patients. The correlations of Center for Epidemiological Studies Depression Scale score with visual acuity and visual-specific disability, however, were not significant after controlling for general physical disability. An increase in depressive symptoms over time predicted decline in self-reported vision function independent of changes in visual acuity or medical status (P<.05). CONCLUSIONS: The prevalence and disabling effects of depression in older patients with AMD are substantial. Recognizing that depression is a treatable disorder that exacerbates the effects of AMD will lead to improved outcomes. Innovative interventions to prevent or treat depression in specialty eye clinics are possible.