Psychological Impact of Vision Loss
Published online Jan. 5, 2015
Irreversible vision loss (IVL) is especially challenging for ophthalmologists because rehabilitation outcomes are strongly dependent on the patient’s psychological adjustment to illness and impairment. In this meta-analysis of IVL in adults, Senra et al. found that it has a negative, long-lasting effect on quality of life and mental health.
The researchers selected 52 studies published between 1946 and 2014 that examined adjustment to IVL. Most were observational and cross-sectional in nature. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized controlled trials and the RTI Item Bank for Assessing Risk of Bias and Confounding for Observational Studies of Interventions or Exposures.
From their review of the literature, the researchers found that mental health issues tend to emerge in the early stages of adaptation to vision loss and remain fairly constant over time—especially in patients who have certain progressive conditions such as diabetic retinopathy. As a result, patients should be referred to appropriate care, including both mental health services and vision rehabilitation programs, early in the adaptation process.
The researchers also suggested that clinicians assess patients’ psychological resilience, social support networks, and practical coping strategies, as these are good predictors of whether a person will find a measure of emotional stability that can be sustained over time.
SD-OCT and Vitreoretinal Interface Abnormalities
Published online Dec. 30, 2014
Meuer et al. used spectral-domain optical coherence tomography (SD-OCT) to estimate the prevalence and interrelationships of several vitreoretinal interface abnormalities. They found that the frequency of two disorders—epiretinal membranes (ERMs) and vitreomacular traction—increase with age and are associated with macular cysts, lamellar macular holes, and visual impairment.
For this population-based study, the researchers evaluated 1,913 participants in the Beaver Dam Eye Study. Of these, 1,540 patients (2,980 eyes) had gradable SD-OCT scans of the macula in at least one eye. Prevalence rates for abnormalities were estimated as follows: ERMs, 34.1 percent; paravascular cysts, 20 percent; macular cysts, 5.6 percent; lamellar macular holes, 3.6 percent; and vitreomacular traction, 1.6 percent.
The prevalence of macular cysts, ERMs, and vitreomacular traction increased with age. The prevalence of paravascular cysts, however, decreased with age, and the researchers found no relationship between lamellar macular holes and age. Eyes with a history of cataract surgery were more likely to have macular cysts, lamellar macular holes, and ERMs; in addition, macular cysts and ERMs were more common in eyes with retinal diseases such as proliferative diabetic retinopathy, retinal vein occlusion, and retinal detachment.
After adjusting for age and sex, the researchers also found that macular cysts, paravascular cysts, lamellar macular holes, vitreomacular traction, and visual impairment were more frequent in eyes with ERMs than in eyes without ERMs.
According to the researchers, two of the main strengths of this study were the use of standardized protocols for measurements and the systematic grading of stereoscopic photographs and SD-OCT scans. One limitation was the limited power to detect associations in eyes with very infrequent conditions. They concluded that further follow-up is necessary to better examine SD-OCT as a tool for risk assessment.
Communication and Adherence to Glaucoma Regimen
Published online Dec. 24, 2014
What can ophthalmologists do to increase patient adherence to a glaucoma medication regimen? Sleath et al. found that the simplest strategy—giving advice on how to accurately administer the drops—is the most effective.
For this prospective, observational cohort study, the researchers enrolled 279 patients at six ophthalmology clinics across the United States. Fifteen ophthalmologists participated in the study as well, and all patient visits were recorded on video. Adherence was assessed for 60 days after the patients’ initial appointments.
The researchers found that physician-provided patient education—such as information on the disease process, the purpose of glaucoma medications, and the potential for medication side effects—had little to no effect on adherence. In contrast, providing patients with practical tips on how to place the drops in the eye and advising them on how long to wait between administering two different drops had a significant positive impact on adherence. And in a positive feedback loop, those patients who reported feeling self-confident with regard to using their medications were more likely to follow their physicians’ recommendations.
The researchers also found that black patients were significantly less likely to adhere to their prescribed regimen. This finding is consistent with earlier studies.
The researchers recommended that physicians simplify their patients’ medication regimens whenever possible, as patients who were prescribed more complex medication schedules were less likely to take their doses on time and less likely to take the correct number of prescribed doses each day.
SD-OCT and Hydroxychloroquine Retinopathy
Published online Dec. 16, 2014
How effective is spectral-domain optical coherence tomography (SD-OCT) in screening patients for hydroxychloroquine (HCQ) retinopathy? Johnston et al. found that it has poor positive predictive value and cannot reliably predict incipient HCQ retinal toxicity when used by itself as a screening tool.
For this study, the researchers evaluated 192 patients who were taking HCQ for various rheumatologic conditions. Median duration of therapy was 9.8 years, and median cumulative dosage was 14.4 g/kg. They used a combination of four standard tests—visual acuity, qualitative and quantitative perimetric visual fields, and fundus examination—for comparison with qualitative and quantitative SD-OCT findings.
A patient’s eye was considered affected if two or more of the standard tests were abnormal. SD-OCT findings were considered abnormal if there was loss of the inner/outer segment line, thinning of the outer nuclear layer, or downward displacement of inner retinal layers.
Two patients were found to have HCQ retinopathy based on both SD-OCT and standard testing. Eight other patients had conflicting test results: Six patients had at least two abnormal standard tests with a qualitatively normal SD-OCT, and two had normal standard tests with a qualitatively abnormal SD-OCT. In addition, the number of abnormal eyes identified by qualitative SD-OCT diverged from that identified by quantitative SD-OCT.
Overall, the researchers concluded that in the presence of an abnormal clinical examination, a qualitatively abnormal SD-OCT is pathognomonic of HCQ retinopathy; however, a qualitatively normal SD-OCT cannot exclude HCQ retinopathy when visual fields or fundus examination are abnormal because of low sensitivity. They therefore proposed minimum retinal thickness measurements to provide additional guidance in the case of equivocal test results.
Ophthalmology summaries are written by Jean Shaw and edited by Susan M. MacDonald, MD.
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