Help needed in medication self-management for people with visual impairment: case-control study

Background: Visual impairment (VI) is rising in prevalence and contributing to increasing morbidity, particularly among older people. Understanding patients' problems is fundamental to achieving optimal health outcomes but little is known about how VI impacts on self-management of medication.

Aim: To compare issues relating to medication self-management between older people with and without VI.

Design and setting: Case-control study with participants aged =65 years, prescribed at least two long-term oral medications daily, living within the community.

Method: The study recruited 156 patients with VI (best corrected visual acuity [BCVA] 6/18 to 3/60) at low-vision clinics; community optometrists identified 158 controls (BCVA 6/9 or better). Researchers visited participants in their homes, administered two validated questionnaires to assess medication adherence (Morisky; Medication Adherence Report Scale [MARS]), and asked questions about medication self-management, beliefs, and support.

Results: Approximately half of the participants in both groups reported perfect adherence on both questionnaires (52.5% Morisky; 43.3%, MARS). Despite using optical aids, few (3%) with VI could read medication information clearly; 24% had difficulty distinguishing different tablets. More people with VI (29%) than controls (13%) (odds ratio [OR] = 2.8; 95% confidence interval [CI] = 1.6 to 5.0) needed help managing their medication, from friends (19% versus 10%) or pharmacists (10% versus 2.5%; OR = 4.4, 95% CI = 1.4 to 13.5); more received social service support (OR = 7.1; 95% CI = 3.9 to 12.9).

Conclusion: Compared to their peers without VI, older people with VI are more than twice as likely to need help in managing medication. In clinical practice in primary care, patients' needs for practical support in taking prescribed treatment must be recognised. Strategies for effective medication self-management should be explored.

Transpupillary thermotherapy for choroidal melanoma:Tumor control and visual results in 100 consecutive cases

Objective: The authors evaluated the results of primary transpupillary thermotherapy for choroidal melanoma in 100 cases. Design: Prospective nonrandomized analysis of treatment method. Participants: One hundred patients with choroidal melanoma were studied. Main Outcome Measures: Tumor response, ocular side effects, and visual results. Results: Of 100 consecutive patients with choroidal melanoma treated with transpupillary thermotherapy, the mean tumor basal diameter was 7.1 mm and tumor thickness was 2.8 mm. The tumor margin touched the optic disc in 34 eyes (34%) and was beneath the fovea in 42 eyes (42%). Documented growth was present in 64 eyes (64%), and known clinical risks for growth were present in all of the remaining 36 eyes (36%), with an average of 4 of 5 statistical risk factors for growth per tumor. After a mean of three treatment sessions and 14 months of follow-up, the mean tumor thickness was reduced to 1.4 mm. Treatment was successful in 94 eyes (94%) and failed in 6 eyes (6%). Three patients with amelanotic tumors showed no initial response to thermotherapy, but subsequent intravenous indocyanine green administration during thermotherapy resulted in improved heat absorption and tumor regression to a flat scar. The six eyes classified as treatment failures included four eyes with tumors that showed partial or no response to thermotherapy, thus requiring plaque radiotherapy or enucleation, and two eyes with recurrence, subsequently controlled with additional thermotherapy. After treatment, the visual acuity was the same (within 1 line) or better than the pretreatment visual acuity in 58 eyes (58%) and worse in 42 eyes (42%). The main reasons for poorer vision included treatment through the foveola for subfoveal tumor (25 eyes), retinal traction (10 eyes), retinal vascular obstruction (5 eyes), optic disc edema (1 eye), and unrelated ocular ischemia (1 eye). Temporal location (versus nasal and superior, P = 0.02) and greater distance from the optic disc (P = 0.04) were risks for retinal traction. Conclusions: Transpupillary thermotherapy may be an effective treatment for small posterior choroidal melanoma, especially those near the optic disc and fovea. Despite satisfactory local tumor control, ocular side effects can result in decreased vision. Longer follow- up will be necessary to assess the impact of thermotherapy on ultimate local tumor control and metastatic disease.

Visual functioning and quality of life in the subfoveal radiotherapy study (SFRADS): SFRADS report 2

Aims: To determine whether or not self reported visual functioning and quality of life in patients with choroidal neovascularisation caused by age related macular degeneration (AMD) is better in those treated with 12 Gy external beam radiotherapy in comparison with untreated subjects. Methods: A multicentre single masked randomised controlled trial of 12 Gy of external beam radiation therapy (EBRT) delivered as 6x2 Gy fractions to the macula of an affected eye versus observation. Patients with AMD, aged 60 years or over, in three UK hospital units, who had subfoveal CNV and a visual acuity equal to or better than 6/60 (logMAR 1.0). Methods: Data from 199 eligible participants who were randomly assigned to 12 Gy teletherapy or observation were available for analysis. Visual function assessment, ophthalmic examination, and fundus fluorescein angiography were undertaken at baseline and at 3, 6, 12, and 24 months after study entry. To assess patient centred outcomes, subjects were asked to complete the Daily Living Tasks Dependent on Vision (DLTV) and the SF-36 questionnaires at baseline, 6, 12, and 24 months after enrolment to the study. Cross sectional and longitudinal analyses were conducted using arm of study as grouping variable. Regression analysis was employed to adjust for the effect of baseline co-variates on outcome at 12 months and 24 months. Results: Both control and treated subjects had significant losses in visual functioning as seen by a progressive decline in mean scores in the four dimensions of the DLTV. There were no statistically significant differences between treatment and control subjects in any of dimensions of the DLTV at 12 months or 24 months after study entry. Regression analysis confirmed that treatment status had no effect on the change in DLTV dimensional scores. Conclusions: The small benefits noted in clinical measures of vision in treated eyes did not translate into better self reported visual functioning in patients who received treatment when compared with the control arm. These findings have implications for the design of future clinical trials and studies.

Exploring eye movement analysis as a measure of selective visual attention in brain injured individuals

Primary Objective: To investigate the utility of using a new method of assessment for deficits in selective visual attention (SVA). Methods and Procedures: An independent groups design compared six participants with brain injuries with six participants from a non-brain injured control group. The Sensomotoric Instruments Eye Movement system with remote eye-tracking device (eye camera), and 2 sets of eight stimuli were employed to determine if the camera would be a sensitive discriminator of SVA in these groups. Main Outcomes and Results: The attention profile displayed by the brain injured group showed that they were slower, made more errors, were less accurate, and more indecisive than the control group. Conclusions: The utility of eye movement analysis as an assessment method was established, with implications for rehabilitation requiring further development. Key words: selective visual attention, eye movement analysis, brain injury

Using time-to-contact information to assess potential collision modulates both visual and temporal prediction networks

Accurate estimates of the time-to-contact (TTC) of approaching objects are crucial for survival. We used an ecologically valid driving simulation to compare and contrast the neural substrates of egocentric (head-on approach) and allocentric (lateral approach) TTC tasks in a fully factorial, event-related fMRI design. Compared to colour control tasks, both egocentric and allocentric TTC tasks activated left ventral premotor cortex/frontal operculum and inferior parietal cortex, the same areas that have previously been implicated in temporal attentional orienting. Despite differences in visual and cognitive demands, both TTC and temporal orienting paradigms encourage the use of temporally predictive information to guide behaviour, suggesting these areas may form a core network for temporal prediction. We also demonstrated that the temporal derivative of the perceptual index tau (tau-dot) held predictive value for making collision judgements and varied inversely with activity in primary visual cortex (V1). Specifically, V1 activity increased with the increasing likelihood of reporting a collision, suggesting top-down attentional modulation of early visual processing areas as a function of subjective collision. Finally, egocentric viewpoints provoked a response bias for reporting collisions, rather than no-collisions, reflecting increased caution for head-on approaches. Associated increases in SMA activity suggest motor preparation mechanisms were engaged, despite the perceptual nature of the task.

Evidence for on-line visual guidance during saccadic gaze shifts.

Rapid orientating movements of the eyes are believed to be controlled ballistically. The mechanism underlying this control is thought to involve a comparison between the desired displacement of the eye and an estimate of its actual position (obtained from the integration of the eye velocity signal). This study shows, however, that under certain circumstances fast gaze movements may be controlled quite differently and may involve mechanisms which use visual information to guide movements prospectively. Subjects were required to make large gaze shifts in yaw towards a target whose location and motion were unknown prior to movement onset. Six of those tested demonstrated remarkable accuracy when making gaze shifts towards a target that appeared during their ongoing movement. In fact their level of accuracy was not significantly different from that shown when they performed a 'remembered' gaze shift to a known stationary target (F-3,F-15 = 0.15, p > 0.05). The lack of a stereotypical relationship between the skew of the gaze velocity profile and movement duration indicates that on-line modifications were being made. It is suggested that a fast route from the retina to the superior colliculus could account for this behaviour and that models of oculomotor control need to be updated.

The control of social attention from 1 to 4 months

The control of social attention during early infancy was investigated in two studies. In both studies, an adult turned towards one of two targets within the infant's immediate visual field. We tested: (a) whether infants were able to follow the direction of the adult's head turn; and (b) whether following a head turn was accompanied by further gaze shifts between experimenter and target. In the first study, 1-month-olds did not demonstrate attention following at the group level. In addition, those infants who turned towards the same target remained fixed on it and did not shift attention again. In Study 2, we tested infants longitudinally at 2-4 months. At the group level, infants followed the adult's head turn at 3 and 4 months but not at 2 months. Those infants who turned towards the same target at 3 and 4 months also shifted gaze back and forth between experimenter and target. By 3 months, infants seem able to capitalize on the social environment to disengage and distribute attention more flexibly. The results support the claim that the control of social attention begins in early infancy, and are consistent with the hypothesis that following the attention of other people is dependent on the development of disengagement skills.

RFID based Efficient Lighting Control

The Kyoto Protocol and the European Energy Performance of Buildings Directive put an onus on governments
and organisations to lower carbon footprint in order to contribute towards reducing global warming. A key
parameter to be considered in buildings towards energy and cost savings is its indoor lighting that has a major
impact on overall energy usage and Carbon Dioxide emissions. Lighting control in buildings using Passive
Infrared sensors is a reliable and well established approach; however, the use of only Passive Infrared does not
offer much savings towards reducing carbon, energy, and cost. Accurate occupancy monitoring information can
greatly affect a building’s lighting control strategy towards a greener usage. This paper presents an approach for
data fusion of Passive Infrared sensors and passive Radio Frequency Identification (RFID) based occupancy
monitoring. The idea is to have efficient, need-based, and reliable control of lighting towards a green indoor
environment, all while considering visual comfort of occupants. The proposed approach provides an estimated
13% electrical energy savings in one open-plan office of a University building in one working day. Practical
implementation of RFID gateways provide real-world occupancy profiling data to be fused with Passive
Infrared sensing towards analysis and improvement of building lighting usage and control.

Adaptations of lateral hand movements to early and late visual occlusion in catching

Recent studies suggested that the control of hand movements in catching involves continuous vision-based adjustments. More insight into these adjustments may be gained by examining the effects of occluding different parts of the ball trajectory. Here, we examined the effects of such occlusion on lateral hand movements when catching balls approaching from different directions, with the occlusion conditions presented in blocks or in randomized order. The analyses showed that late occlusion only had an effect during the blocked presentation, and early occlusion only during the randomized presentation. During the randomized presentation movement biases were more leftward if the preceding trial was an early occlusion trial. The effect of early occlusion during the randomized presentation suggests that the observed leftward movement bias relates to the rightward visual acceleration inherent to the ball trajectories used, while its absence during the blocked presentation seems to reflect trial-by-trial adaptations in the visuomotor gain, reminiscent of dynamic gain control in the smooth pursuit system. The movement biases during the late occlusion block were interpreted in terms of an incomplete motion extrapolation--a reduction of the velocity gain--caused by the fact that participants never saw the to-be-extrapolated part of the ball trajectory. These results underscore that continuous movement adjustments for catching do not only depend on visual information, but also on visuomotor adaptations based on non-visual information.

How position, velocity, and temporal information combine in the prospective control of catching:data and model

The cerebral cortex contains circuitry for continuously computing properties of the environment and one's body, as well as relations among those properties. The success of complex perceptuomotor performances requires integrated, simultaneous use of such relational information. Ball catching is a good example as it involves reaching and grasping of visually pursued objects that move relative to the catcher. Although integrated neural control of catching has received sparse attention in the neuroscience literature, behavioral observations have led to the identification of control principles that may be embodied in the involved neural circuits. Here, we report a catching experiment that refines those principles via a novel manipulation. Visual field motion was used to perturb velocity information about balls traveling on various trajectories relative to a seated catcher, with various initial hand positions. The experiment produced evidence for a continuous, prospective catching strategy, in which hand movements are planned based on gaze-centered ball velocity and ball position information. Such a strategy was implemented in a new neural model, which suggests how position, velocity, and temporal information streams combine to shape catching movements. The model accurately reproduces the main and interaction effects found in the behavioral experiment and provides an interpretation of recently observed target motion-related activity in the motor cortex during interceptive reaching by monkeys. It functionally interprets a broad range of neurobiological and behavioral data, and thus contributes to a unified theory of the neural control of reaching to stationary and moving targets.

A comparison of real catching with catching using stereoscopic visual displays

To date, the usefulness of stereoscopic visual displays in research on manual interceptive actions has never been examined. In this study, we compared the catching movements of 8 right-handed participants (6 men, 2 women) in a real environment (with suspended balls swinging past the participant, requiring lateral hand movements for interception) with those in a situation in which similar virtual ball trajectories were displayed stereoscopically in a virtual reality system (Cave Automated Virtual Environment [CAVE]; Cruz-Neira, Sandin, DeFranti, Kenyon, & Hart, 1992) with the head fixated. Catching the virtual ball involved grasping a lightweight ball attached to the palm of the hand. The results showed that, compared to real catching, hand movements in the CAVE were (a) initiated later, (b) less accurate, (c) smoother, and (d) aimed more directly at the interception point. Although the latter 3 observations might be attributable to the delayed movement initiation observed in the CAVE, this delayed initiation might have resulted from the use of visual displays. This suggests that stereoscopic visual displays such as present in many virtual reality systems should be used circumspectly in the experimental study of catching and should be used only to address research questions requiring no detailed analysis of the information-based online control of the catching movements.