Amblyopia treatment : an evidence-based approach to maximising treatment outcome

The basis of treatment for amblyopia (poor vision due to abnormal visual experience early in life) for 250 years has been patching of the unaffected eye for extended times to ensure a period of use of the affected eye. Over the last decade randomised controlled treatment trials have provided some evidence on how to tailor amblyopia therapy more precisely to achieve the best visual outcome with the least negative impact on the patient and the family. This review highlights the expansion of knowledge regarding treatment for amblyopia and aims to provide optometrists with a summary of research evidence to enable them to better treat amblyopia. Treatment for amblyopia is effective, as it reduces overall prevalence and severity of visual loss in this population. Correction of refractive error alone significantly improves visual acuity, sometimes to the point where further amblyopia treatment is not required. Atropine penalisation and patch occlusion are effective in treating amblyopia. Lesser amounts of occlusion or penalisation have been found to be just as effective as greater amounts. Recent evidence has highlighted that occlusion or penalisation in amblyopia treatment can create negative changes in behaviour in children and impact on family life. These complications should be considere when prescribing treatment because they can negatively affect compliance. Studies investigating the maximum age at which treatment of amblyopia can still be effective and the importance of near activities during occlusion are ongoing.

Vision, functional and cognitive determinants of motor vehicle incidents in older drivers

Background: The proportion of older individuals in the driving population is predicted to increase in the next 50 years. This has important implications for driving safety as abilities which are important for safe driving, such as vision (which accounts for the majority of the sensory input required for driving), processing ability and cognition have been shown to decline with age. The current methods employed for screening older drivers upon re-licensure are also vision based. This study, which investigated social, behavioural and professional aspects involved with older drivers, aimed to determine: (i) if the current visual standards in place for testing upon re-licensure are effective in reducing the older driver fatality rate in Australia; (ii) if the recommended visual standards are actually implemented as part of the testing procedures by Australian optometrists; and (iii) if there are other non-standardised tests which may be better at predicting the on-road incident-risk (including near misses and minor incidents) in older drivers than those tests recommended in the standards. Methods: For the first phase of the study, state-based age- and gender-stratified numbers of older driver fatalities for 2000-2003 were obtained from the Australian Transportation Safety Bureau database. Poisson regression analyses of fatality rates were considered by renewal frequency and jurisdiction (as separate models), adjusting for possible confounding variables of age, gender and year. For the second phase, all practising optometrists in Australia were surveyed on the vision tests they conduct in consultations relating to driving and their knowledge of vision requirements for older drivers. Finally, for the third phase of the study to investigate determinants of on-road incident risk, a stratified random sample of 600 Brisbane residents aged 60 years and were selected and invited to participate using an introductory letter explaining the project requirements. In order to capture the number and type of road incidents which occurred for each participant over 12 months (including near misses and minor incidents), an important component of the prospective research study was the development and validation of a driving diary. The diary was a tool in which incidents that occurred could be logged at that time (or very close in time to which they occurred) and thus, in comparison with relying on participant memory over time, recall bias of incident occurrence was minimised. Association between all visual tests, cognition and scores obtained for non-standard functional tests with retrospective and prospective incident occurrence was investigated. Results: In the first phase,rivers aged 60-69 years had a 33% lower fatality risk (Rate Ratio [RR] = 0.75, 95% CI 0.32-1.77) in states with vision testing upon re-licensure compared with states with no vision testing upon re-licensure, however, because the CIs are wide, crossing 1.00, this result should be regarded with caution. However, overall fatality rates and fatality rates for those aged 70 years and older (RR=1.17, CI 0.64-2.13) did not differ between states with and without license renewal procedures, indicating no apparent benefit in vision testing legislation. For the second phase of the study, nearly all optometrists measured visual acuity (VA) as part of a vision assessment for re-licensing, however, 20% of optometrists did not perform any visual field (VF) testing and only 20% routinely performed automated VF on older drivers, despite the standards for licensing advocating automated VF as part of the vision standard. This demonstrates the need for more effective communication between the policy makers and those responsible for carrying out the standards. It may also indicate that the overall higher driver fatality rate in jurisdictions with vision testing requirements is resultant as the tests recommended by the standards are only partially being conducted by optometrists. Hence a standardised protocol for the screening of older drivers for re-licensure across the nation must be established. The opinions of Australian optometrists with regard to the responsibility of reporting older drivers who fail to meet the licensing standards highlighted the conflict between maintaining patient confidentiality or upholding public safety. Mandatory reporting requirements of those drivers who fail to reach the standards necessary for driving would minimise potential conflict between the patient and their practitioner, and help maintain patient trust and goodwill. The final phase of the PhD program investigated the efficacy of vision, functional and cognitive tests to discriminate between at-risk and safe older drivers. Nearly 80% of the participants experienced an incident of some form over the prospective 12 months, with the total incident rate being 4.65/10 000 km. Sixty-three percent reported having a near miss and 28% had a minor incident. The results from the prospective diary study indicate that the current vision screening tests (VA and VF) used for re-licensure do not accurately predict older drivers who are at increased odds of having an on-road incident. However, the variation in visual measurements of the cohort was narrow, also affecting the results seen with the visual functon questionnaires. Hence a larger cohort with greater variability should be considered for a future study. A slightly lower cognitive level (as measured with the Mini-Mental State Examination [MMSE]) did show an association with incident involvement as did slower reaction time (RT), however the Useful-Field-of-View (UFOV) provided the most compelling results of the study. Cut-off values of UFOV processing (>23.3ms), divided attention (>113ms), selective attention (>258ms) and overall score (moderate/ high/ very high risk) were effective in determining older drivers at increased odds of having any on-road incident and the occurrence of minor incidents. Discussion: The results have shown that for the 60-69 year age-group, there is a potential benefit in testing vision upon licence renewal. However, overall fatality rates and fatality rates for those aged 70 years and older indicated no benefit in vision testing legislation and suggests a need for inclusion of screening tests which better predict on-road incidents. Although VA is routinely performed by Australian optometrists on older drivers renewing their licence, VF is not. Therefore there is a need for a protocol to be developed and administered which would result in standardised methods conducted throughout the nation for the screening of older drivers upon re-licensure. Communication between the community, policy makers and those conducting the protocol should be maximised. By implementing a standardised screening protocol which incorporates a level of mandatory reporting by the practitioner, the ethical dilemma of breaching patient confidentiality would also be resolved. The tests which should be included in this screening protocol, however, cannot solely be ones which have been implemented in the past. In this investigation, RT, MMSE and UFOV were shown to be better determinants of on-road incidents in older drivers than VA and VF, however, as previously mentioned, there was a lack of variability in visual status within the cohort. Nevertheless, it is the recommendation from this investigation, that subject to appropriate sensitivity and specificity being demonstrated in the future using a cohort with wider variation in vision, functional performance and cognition, these tests of cognition and information processing should be added to the current protocol for the screening of older drivers which may be conducted at licensing centres across the nation.

Age-related development of a refractive index plateau in the human lens : evidence for a distinct nucleus

The human lens comprises two distinct regions in which the refractive index changes at different rates. The periphery contains a rapidly increasing refractive index gradient, which becomes steeper with age. The inner region contains a shallow gradient, which flattens with age, due to formation of a central plateau, of RI = 1.418, which reaches a maximum size of 7.0 × 3.05 mm around age 60 years. Formation of the plateau can be attributed to compression of fibre cells generated in prenatal life. Present in prenatal but not in postnatal fibre cells, γ-crystallin may play a role in limiting nuclear cell compression.

Low Vision

The care of low-vision patients is termed vision rehabilitation, and optometrists have an essential role to play in the provision of vision rehabilitation services. Ideally, if patients stay with one optometrist or practice, their low-vision care becomes part of a continuum of eye care, from the time when they had normal vision. If progressive vision loss occurs, the role of the optometrist changes from primary eye care only to one of monitoring vision loss and gradually introducing low-vision care, especially magnification and advice on lighting and contrast, in conjunction with other vision rehabilitation professionals.

Unilateral pseudogerontoxon

Peripheral corneal opacities are a common clinical finding. In this case report we describe the routine presentation of a young adult male patient with unilateral opacities in the peripheral cornea resembling a corneal arcus. These opacities were confined to the level of the anterior corneal stroma. The patient also exhibited bilateral signs of mild keratoconus and reported a history of vernal keratoconjunctivitis as a child. A diagnosis of unilateral pseudogerontoxon was made. Pseudogerontoxon is an opacity of the peripheral cornea resembling corneal arcus that typically occurs in patients with a history of allergic eye disease. The clinical features and differential diagnoses of this relatively uncommon cause of peripheral corneal opacity are discussed.

Practitioner influence on contact lens prescribing in the UK

Contact lenses are mainly fitted by registered optometrists and contact lens opticians in the UK. Data we have gathered from annual contact lens fitting surveys over the past 12 years indicate that, on average, registered optometrists and contact lens opticians undertake 3.2 and 7.1 contact lens fits per week (p < 0.0001). More experienced practitioners tend to fit older patients. Practitioners fitting more lenses per year tend to fit a higher proportion of soft lenses. Contact lens opticians tend to fit a higher proportion of patients with planned replacement and daily disposable lenses compared with optometrists.

The performance of a prolonged reading task by students with low vision

Purpose: Students often read for long periods and prolonged reading practice may be important for developing reading skills. For students with low vision, reading at a close working distance imposes high demands on their near visual functions, which might make it difficult to sustain prolonged reading. The aim of this study was to investigate the performance of a prolonged reading task by students with low vision. Method: Forty students with low vision, aged from eight to 20 years and without any intellectual, reading or learning disability, were recruited through the Paediatric Low Vision Clinic, Buranda, Queensland. Following a preliminary vision examination, reading performance measures—critical print size (CPS), maximum oral reading rates (MORR), near text visual acuity— were recorded using the Bailey-Lovie text reading charts before and after a 30-minute prolonged reading task. Results: The mean age of the participants was 13.03 ± 3 years. The distance and near visual acuities ranged between -0.1 to 1.24 logMAR and 0.0 to 1.60 logMAR, respectively. The mean working distance of the participants was 11.2 ± 5.8 cm. Most of the participants (65 per cent) in this study were able to complete the prolonged reading task. Overall, there was no significant change in CPS, MORR and near text visual acuity following the prolonged task (p > 0.05). MORR was significantly correlated to age and near text visual acuity (p < 0.05). Conclusions: In this study, students with low vision were able to maintain their reading performance over a 30-minute prolonged reading task. Overall, there was no significant increase or decrease in reading performance following a prolonged reading task performed at their habitual close working distances but there were wide individual variations within the group.

Visual impairment, postural stability and falls among older adults with glaucoma

Purpose: To investigate the impact of glaucomatous visual impairment on postural sway and falls among older adults.Methods: The sample comprised 72 community-dwelling older adults with open-angle glaucoma, aged 74.0 5.8 years (range 62 to 90 years). Measures of visual function included binocular visual acuity (high-contrast), binocular contrast sensitivity (Pelli- Robson) and binocular visual fields (merged monocular HFA 24-2 SITA-Std). Postural stability was assessed under four conditions: eyes open and closed, on a firm and on a foam surface. Falls were monitored for six months with prospective falls diaries. Regression models, adjusting for age and gender, examined the association between vision measures and postural stability (linear regression) and the number of falls (negative binomial regression). Results: Greater visual field loss was significantly associated with poorer postural stability with eyes open, both on firm (r = 0.34, p < 0.01) and foam (r = 0.45, p < 0.001) surfaces. Eighteen (25 per cent) participants experienced at least one fall: 12 (17 per cent) participants fell only once and six (eight per cent) participants fell two or more times (up to five falls). Visual field loss was significantly associated with falling; the rate of falls doubled for every 10 dB reduction in field sensitivity (rate ratio = 1.08, 95% CI = 1.02–1.13). Importantly, in a model comprising upper and lower field sensitivity, only lower field loss was significantly associated with the number of falls (rate ratio = 1.17, 95% CI = 1.04–1.33). Conclusions: Binocular visual field loss was significantly associated with postural instability and falls among older adults with glaucoma. These findings provide valuable directions for developing falls risk assessment and falls prevention strategies for this population.

Can students with low vision maintain sustained reading rates?

Purpose: Students with low vision may be disadvantaged when compared with their normally sighted peers, as they frequently work at very short working distances and need to use low vision devices. The aim of this study was to examine the sustained reading rates of students with low vision and compare them with their peers with normal vision. The effects of visual acuity, acuity reserve and age on reading rate were also examined. Method: Fifty-six students (10 to 16 years of age), 26 with low vision and 30 with normal vision were required to read text continuously for 30 minutes. Their position in the text was recorded at two-minute intervals. Distance and near visual acuity, working distance, cause of low vision, reading rates and reading habits were recorded. Results: A total of 80.7 per cent of the students with low vision maintained a constant reading rate during the 30 minutes of reading, although they read at approximately half the rate (104 wpm) compared with their normally sighted peers (195 wpm). Only four of the low vision subjects could not complete the reading task. Reading rates increased significantly with acuity reserve and distance and near visual acuity but there was no significant relationship between age and sustained reading rate. Conclusions: The majority of students with low vision were able to maintain appropriate reading rates to cope in integrated educational settings. Surprisingly only relatively few subjects (16 per cent) used their prescribed low vision devices even though the average accommodative demand was 9 D and generally, they revealed a greater dislike of reading compared to students with normal vision.

Empirical measurement of the Enright phenomenon, a distortion of perceived driving speed

Purpose: In 1970, Enright observed a distortion of perceived driving speed, induced by monocular application of a neutral density (ND) filter. If a driver looks out of the right side of a vehicle with a filter over the right eye, the driver perceives a reduction of the vehicle’s apparent velocity, while applying a ND filter over the left eye increases the vehicle’s apparent velocity. The purpose of the current study was to provide the first empirical measurements of the Enright phenomenon. Methods: Ten experienced drivers were tested and drove an automatic sedan on a closed road circuit. Filters (0.9 ND) were placed over the left, right or both eyes during a driving run, in addition to a control condition with no filters in place. Subjects were asked to look out of the right side of the car and adjust their driving speed to either 40 km/h or 60 km/h. Results: Without a filter or with both eyes filtered subjects showed good estimation of speed when asked to travel at 60 km/h but travelled a mean of 12 to 14 km/h faster than the requested 40 km/h. Subjects travelled faster than these baselines by a mean of 7 to 9 km/h (p < 0.001) with the filter over their right eye, and 3 to 5 km/h slower with the filter over their left eye (p < 0.05). Conclusions: The Enright phenomenon causes significant and measurable distortions of perceived driving speed under realworld driving conditions.

Development of a method to measure upper eyelid pressure on the cornea

Purpose: The cornea is known to be susceptible to forces exerted by eyelids. There have been previous attempts to quantify eyelid pressure but the reliability of the results is unclear. The purpose of this study was to develop a technique using piezoresistive pressure sensors to measure upper eyelid pressure on the cornea. Methods: The technique was based on the use of thin (0.18 mm) tactile piezoresistive pressure sensors, which generate a signal related to the applied pressure. A range of factors that influence the response of this pressure sensor were investigated along with the optimal method of placing the sensor in the eye. Results: Curvature of the pressure sensor was found to impart force, so the sensor needed to remain flat during measurements. A large rigid contact lens was designed to have a flat region to which the sensor was attached. To stabilise the contact lens during measurement, an apparatus was designed to hold and position the sensor and contact lens combination on the eye. A calibration system was designed to apply even pressure to the sensor when attached to the contact lens, so the raw digital output could be converted to actual pressure units. Conclusions: Several novel procedures were developed to use tactile sensors to measure eyelid pressure. The quantification of eyelid pressure has a number of applications including eyelid reconstructive surgery and the design of soft and rigid contact lenses.

Influence of presbyopic corrections on driving-related eye and head movements

Purpose: To investigate whether wearing different presbyopic refractive corrections alters the pattern of eye and head movements when searching for dynamic targets in driving-related traffic scenes. Methods: Eye and head movements of 20 presbyopes (mean age = 56.2 ± 5.7 years), who had no experience of wearing presbyopic corrections or were unadapted wearers were recorded using the faceLABTM eye and head tracker, while wearing five different corrections: single vision lenses (SV), progressive addition lenses (PALs), bifocal spectacles (BIF), monovision and multifocal contact lenses (MTF CLs) in random order (within-subjects comparison). Recorded traffic scenes of suburban roads and expressways with edited targets were viewed as dynamic stimuli. Results: The magnitude of eye and head movements was significantly greater for SV, BIF and PALs than monovision and MTF CLs (p < 0.001). In addition, BIF wear led to more eye movements than PAL wear (p = 0.017), while PAL wear resulted in greater head movements than SV wear (p = 0.018). The ratio of eye to head movement was smaller for PALs than all other groups (p < 0.001). The number of saccades made to fixate a target was significantly higher for BIF and PALs than monovision or MTF CLs (p < 0.05). Conclusions: Different presbyopic corrections can alter eye and head movement patterns. Wearing spectacles such as BIF and PALs produced relatively greater eye and head movements and saccades when viewing dynamic targets. The impact of these changes in eye and head movement patterns may have implications for driving performance under real world driving conditions.