AREDS: Ten-year AMD Follow-up

Staff
5/8/2014

In order to provide long-term follow-up on the natural history of age-related macular degeneration and associated risk factors, the Age-Related Eye Disease Study Group tracked surviving AREDS participants for an additional five years after the randomized clinical trial of antioxidant vitamins and minerals was completed. Their results indicate a relentless loss of vision in persons who develop advanced AMD.

Following the completion of AREDS, 3,549 of the surviving 4,203 participants were followed for an additional five years, with researchers focusing on the development of varying stages of AMD and changes in visual acuity. The rates of progression to large drusen and advanced AMD (neovascular AMD or central geographic atrophy) were evaluated using annual fundus photographs assessed centrally. Best-corrected visual acuity was measured at annual study visits.

The risk of progression to advanced AMD increased with age (p=0.01) and severity of drusen. Women (p=0.005) and current smokers (p<0.001) were at increased risk of neovascular AMD. In the oldest participants with the most severe AMD at baseline, the risks of developing neovascular AMD and central geographic atrophy by 10 years were 48.1 percent and 26 percent, respectively. Similarly, rates of progression to large drusen increased with increasing severity of drusen at baseline, with 70.9 percent of participants with bilateral medium drusen progressing to large drusen and 13.8 percent to advanced AMD in 10 years. Median visual acuity at 10 years in eyes that had large drusen at baseline but never developed advanced AMD was 20/25; eyes that developed advanced AMD had a median visual acuity of 20/200.
JAMA Ophthalmol 2014;132:272-277. 
Chew E, Clemons T, Agron E, Sperduto R, et al.


Axial Length Not Predictor of Elevated IOP After IVI
Researchers have determined that there is no association of axial length or postinjection reflux with transient or sustained intraocular pressure elevation in patients with neovascular age-related macular degeneration who are receiving anti-VEGF injections. 

One hundred and forty-seven eyes from 74 consecutive patients with neovascular AMD who presented to a single physician over a two-month period had their axial lengths measured by IOLMaster. Of these, 21 patients had preinjection and immediate postinjection IOP measured and their immediate reflux assessed.

In a previous study, 9.5 percent of eyes had been identified with sustained IOP elevation. Axial length did not significantly differ between eyes that had and had not experienced sustained IOP elevation (axial length, 23.96 ±0.66 mm; n=14 and axial length 23.44 ±1.24 mm; n=133; p=0.12). By linear regression analysis, the relationship between experiencing sustained IOP elevation and axial length was not statistically significant (R2=0.0165; p=0.121). The relationship between axial length and immediate postinjection IOP elevation was also not statistically significant (R2=0.0001; p=0.97). Immediate postinjection IOP increase did differ between eyes without reflux (30.2 ±9.3 mmHg; n=12) and those with reflux (1.1 ±7.2; n=9; p<0.001).
Retina 2014;34:519-524.
Hoang Q, Jung J, Mrejen S, Freund K.


Relationship Between Pathologic Myopia and Dry Eye Examined
A Turkish study investigating the relationship between pathologic myopia and dry-eye syndrome found that patients with pathological myopia have lower tear breakup time and higher ocular surface disease index scores compared to healthy individuals.

Forty-five patients with a spherical equivalence greater than -6 D and an axial length >26.5 mm were assigned to the pathological myopia group (Group 1). Forty-four healthy individuals were selected from subjects with emmetropia whose spherical equivalence values ranged from -1 to +1 D (Group 2). OSDI scores of all the patients were determined, with all participants undergoing the following: Schirmer 1 test without anesthesia; corneal staining; TBUT; Schirmer test with anesthesia; and axial length measurement.

The mean ages of Group 1 and Group 2 patients were 40.2 ±12.3 and 38.8 ±9.3 years. The mean values of spherical equivalence, keratometry and axial length were -9.6 ±3.8 D, 43.9 ±1.1 D and 27.4 ±0.6 mm in Group 1 and -0.1 ±0.5 D, 42.3 ±1.4 D and 23 ±0.2 mm in Group 2. The mean values of the Schirmer 1 test without and with anesthesia were 14.4 ±6.1 and 9.5 ±4.5 mm in Group 1 and 16.7 ±6.2 and 11.4 ±6 mm in Group 2. The mean TBUT in Group 1 was 7.2 ±3.4 seconds, whereas the mean TBUT in Group 2 was 13.6 ±3.7 seconds. There was a significant difference between the groups in spherical equivalence, keratometry, axial length, TBUT and OSDI scores (p<0.001).
Cornea 2014;33:169-171.
Ilhan N, Ilhan O, Tuzcu E, Daglioglu M, et al.


Goldman Applanation Tonometry Underestimates POAG IOP
Ohio researchers have determined that the delta differences between Goldman applanation tonometry and newer measures of intraocular pressure are greater in magnitude in patients with primary open-angle glaucoma than in normal control groups, regardless of central corneal thickness. This is likely due to differences in corneal biomechanical properties, with POAG corneas being softer than healthy corneas, causing greater underestimation of IOP by GAT in POAG than in controls. 

Thirteen eyes of 13 POAG patients and 15 eyes of 15 control patients underwent corneal topography; IOP measurement using GAT, dynamic contour tonometry (DCT) and corneal compensated IOP (IOPcc) using the Reichert ocular response analyzer (ORA); corneal hysteresis; and CCT. Results from POAG and control eyes were then compared using t tests.

Ages in the POAG group were slightly greater than those of the control group. CCT was also closely matched between groups. However, significant differences were found between GAT vs. DCT and GAT vs. IOPcc within both groups: Mean GAT IOP was not significantly different between POAG and controls, whereas mean DCT IOP did show a significant difference between groups, as did mean IOPcc. The delta differences, GATΔDCT and GATΔIOPcc, were of greater magnitude in POAG subjects when compared with controls. Corneal hysteresis was also significantly lower in POAG subjects.
J Glaucoma 2014;23:69-74.
Costin B, Fleming G, Weber P, Mahmoud A, et al.


Glaucoma Screening Using Relative Afferent Pupillary Defect
Stanford doctors assessed the relative afferent pupillary defect observed during the swinging flashlight test as a quick, inexpensive, easily performed screening test for glaucomatous optic neuropathy, finding that RAPD screening with neutral density filters was moderately sensitive and strongly specific for glaucoma. Sensitivity, specificity and predictive value improved when patients who had previously undergone cataract surgery were removed from the analysis.

The doctors recruited 107 subjects from a mixed population of glaucomatous and nonglaucomatous patients. All subjects underwent a swinging flashlight test with, when necessary, the aid of a neutral density filter, to determine whether or not RAPD was present. A determination of glaucoma diagnosis, as well as classification of disease stage, was subsequently assessed based upon review of history and ophthalmic examination. The non-ophthalmologist performing the swinging flashlight test was masked to disease presence, and the clinical information regarding glaucomatous disease was ascertained without knowledge of study RAPD status. 

Statistical analysis demonstrated an odds ratio of 9.71 (95 percent CI, 3.72 to 25.4) for glaucomatous disease if RAPD was present, with a sensitivity of 66.7 percent and a specificity of 82.9 percent. Patients who had not previously undergone cataract surgery revealed an odds ratio of 17.05 percent (95 percent CI, 4.73 to 61.44) for glaucomatous disease if a RAPD was present, with a sensitivity of 68.8 percent and a specificity of 88.6 percent.
J Glaucoma 2014;23:169-173.
Charalel R, Lin S, Singh K.


Long-term Follow-up After LVC in Physicians
A cohort study sent to physicians who had refractive surgery at the Cole Eye Institute between 2000 and 2012 indicates that, despite high visual demands, physicians who had laser vision correction had a high percentage of good visual outcomes, satisfaction and quality of life improvements.

A 12-question survey targeted toward physicians and their experiences with refractive surgery was sent to 226 physicians (439 eyes). Of those, 132 (58 percent) responded, reporting an overall satisfaction rate of 95.3 percent. Respondents included surgeons (28 percent), physicians who perform procedures but not surgery (43.2 percent) and physicians who do not perform procedures or surgeries (28.8 percent). Of the physicians, 84.8 percent reported an improvement in the quality of vision compared with corrected preoperative vision, 39 percent reported that their ability to perform procedures accurately had improved and 1.6 percent said they believed their ability to perform procedures was less. The majority of physicians (96 percent) said that they would have the procedure again.
J Cataract Refract Surg 2014;40:395-402.
Pasquali T, Smadja D, Savetsky M, Reggiani G, et al.