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Purpose To develop a novel deep-learning approach that can describe the structural phenotype of the glaucomatous ONH and can be used as a robust glaucoma diagnosis tool. Design Retrospective, deep-learning approach diagnosis study. Method We trained a deep learning network to segment three neural-tissue and four connective-tissue layers of the ONH. The segmented OCT images were then processed by a customized autoencoder network with an additional parallel branch for binary classification. The encoder part of the autoencoder reduced the segmented OCT images into a low-dimensional latent space (LS); whereas the decoder and the classification branches reconstructed the images and classified them as glaucoma or non-glaucoma, respectively. We performed principal component analysis on the latent parameters and identified the principal components (PCs). Subsequently, the magnitude of each PC was altered in steps and reported how it impacted the morphology of the ONH. Results The image reconstruction quality and diagnostic accuracy increased with the size of the LS. With 54 parameters in the LS, the diagnostic accuracy was 92.0±2.3% with a sensitivity of 90.0±2.4% (at 95% specificity), and the corresponding Dice coefficient for the reconstructed images was 0.86±0.04. By changing the magnitudes of PC in steps, we were able to reveal how the morphology of the ONH changes as one transitions from a ‘non-glaucoma’ to a ‘glaucoma’ condition. Conclusions Our network was able to identify novel biomarkers of the ONH for glaucoma diagnosis. Specifically, the structural features identified by our algorithm were found to be related to clinical observations of glaucoma.

Purpose We hypothesized that the effect of blood lipid–related metabolites on primary open-angle glaucoma (POAG) would differ according to specific lipoprotein particles and lipid sub-fractions. We investigated the associations of blood levels of lipoprotein particles and lipid sub-fractions with POAG. Design Cross-sectional study. Participants Individuals recruited for the baseline visit of the population-based Singapore Epidemiology of Eye Disease study (n = 8503). Methods All participants underwent detailed standardized ocular and systemic examinations. A total of 130 blood lipid–related metabolites were quantified using a nuclear magnetic resonance metabolomics platform. The analyses were conducted in 2 stages. First, we investigated whether and which lipid-related metabolites were directly associated with POAG using regression analyses followed by Bayesian network modeling. Second, we investigated if any causal relationship exists between the identified lipid-related metabolites, if any, and POAG using 2-sample Mendelian randomization (MR) analysis. We performed genome-wide association studies (GWAS) on high-density lipoprotein (HDL) 3 cholesterol (after inverse normal transformation) and used the top variants associated with HLD3 cholesterol as instrumental variables (IVs) in the MR analysis. Main Outcome Measure Primary open-angle glaucoma. Results Of the participants, 175 (2.1%) had POAG. First, a logistic regression model showed that total HDL3 cholesterol (negatively) and phospholipids in very large HDL (positively) were associated with POAG. Further analyses using a Bayesian network analysis showed that only total HDL3 cholesterol was directly associated with POAG (odds ratio [OR], 0.72 per 1 standard deviation increase in HDL3 cholesterol; 95% confidence interval [CI], 0.61–0.84), independently of age, gender, intraocular pressure (IOP), body mass index (BMI), education level, systolic blood pressure, axial length, and statin medication. Using 5 IVs identified from the GWAS and with the inverse variance weighted MR method, we found that higher levels of HDL3 cholesterol were associated with a decreased odds of POAG (OR, 0.91; 95% CI, 0.84–0.99, P = 0.021). Other MR methods, including weighted median, mode-based estimator, and contamination mixture methods, derived consistent OR estimates. None of the routine lipids (blood total, HDL, or low-density lipoprotein [LDL] cholesterol) were associated with POAG. Conclusions Overall, these results suggest that the relationship between HDL3 cholesterol and POAG might be causal and specific, and that dysregulation of cholesterol transport may play a role in the pathogenesis of POAG.

Purpose To determine whether eyes with pathologic myopia can be identified and whether each type of myopic maculopathy lesion on fundus photographs can be diagnosed by deep learning (DL) algorithms. Design A DL algorithm was developed to recognize myopic maculopathy features and to categorize the myopic maculopathy automatically. Participants We examined 7020 fundus images from 4432 highly myopic eyes obtained from the Advanced Clinical Center for Myopia. Methods Deep learning (DL) algorithms were developed to recognize the key features of myopic maculopathy with 5176 fundus images. These algorithms were also used to develop a Meta-analysis for Pathologic Myopia (META-PM) study categorizing system (CS) by adding a specific processing layer. Models and the system were evaluated by 1844 fundus image. The area under the receiver operating characteristic curve (AUC), sensitivity, and specificity were used to determine the performance of each DL algorithm. The rate of correct predictions was used to determine the performance of the META-PM study CS. Main Outcome Measures Four trained DL models were able to recognize the lesions of myopic maculopathy accurately with high sensitivity and specificity. The META-PM study CS also showed a high accuracy and was qualified to be used in a semiautomated way during screening for myopic maculopathy in highly myopic eyes. Results The sensitivity of the DL models was 84.44% for diffuse atrophy, 87.22% for patchy atrophy, 85.10% for macular atrophy, and 37.07% for choroidal neovascularization, and the AUC values were 0.970, 0.978, 0.982, and 0.881, respectively. The rate of total correct predictions from the META-PM study CS was 87.53%, with rates of 90.18%, 95.28%, 97.50%, and 91.14%, respectively, for each type of lesion. The META-PM study CS showed an overall rate of 92.08% in detecting pathologic myopia correctly, which was defined as having myopic maculopathy equal to or more serious than diffuse atrophy. Conclusions The novel DL models and system can achieve high sensitivity and specificity in identifying the different types of lesions of myopic maculopathy. These results will assist in the screening for pathologic myopia and subsequent protection of patients against low vision and blindness caused by myopic maculopathy.

Vision impairment (VI) is associated with poor quality of life and increased risk of falls. Few prospective data are available on Asians. This study investigates the longitudinal impact of VI and the major eye diseases on mortality risk in Asians.Prospective cohort study with meta-analysis.We conducted a multi-ethnic prospective study of adults (40-80 years old) in the Singapore Epidemiology of Eye Diseases Study (baseline: 2004-2011). All-cause mortality was obtained from the National Death Registry until May 2017. VI was defined by best-corrected visual acuity (BCVA)20/40 in the better eye. Major eye diseases were assessed using standard protocols. We examined associations using multivariate-adjusted Cox proportional hazards regression models. Finally, we conducted a meta-analysis of the associations between VI and mortality.Of 9,986 participants, 1,210 deaths occurred (12.1%) over a median follow-up of 8.8 years. Compared to participants with normal vision, persons with VI had increased risk of mortality (hazards ratio [HR]: 1.53; 95% confidence interval [CI:] 1.30-1.81) in multivariate models. In ethnicity-specific analyses, this association was significant across Chinese (HR: 1.63; 95% CI: 1.08-2.48); Malays (HR: 1.31; 95% CI: 1.06-1.62); and Indians (HR: 2.25; 95% CI: 1.61-3.15). Cataract, under-corrected refractive errors (URE), and diabetic retinopathy (DR) were significantly associated with mortality (HRs: 1.30, 1.22, and 1.54, respectively). In a meta-analysis of 12 studies including 58,034 persons, VI was associated with 30% increased risk of mortality (HR: 1.3; 95% CI: 1.2-1.5).In this multi-ethnic Asian population, VI and preventable eye conditions (cataract, URE, and DR) were associated with mortality, emphasizing the need for early detection and intervention to prevent and treat VI and major eye diseases.

Topic To provide updated estimates on the global prevalence and number of people with diabetic retinopathy (DR) through 2045. Clinical Relevance The International Diabetes Federation (IDF) estimated the global population with diabetes mellitus (DM) to be 463 million in 2019 and 700 million in 2045. Diabetic retinopathy remains a common complication of DM and a leading cause of preventable blindness in the adult working population. Methods We conducted a systematic review using PubMed, Medline, Web of Science, and Scopus for population-based studies published up to March 2020. Random effect meta-analysis with logit transformation was performed to estimate global and regional prevalence of DR, vision-threatening DR (VTDR), and clinically significant macular edema (CSME). Projections of DR, VTDR, and CSME burden were based on population data from the IDF Atlas 2019. Results We included 59 population-based studies. Among individuals with diabetes, global prevalence was 22.27% (95% confidence interval [CI], 19.73%–25.03%) for DR, 6.17% (95% CI, 5.43%–6.98%) for VTDR, and 4.07% (95% CI, 3.42%–4.82%) for CSME. In 2020, the number of adults worldwide with DR, VTDR, and CSME was estimated to be 103.12 million, 28.54 million, and 18.83 million, respectively; by 2045, the numbers are projected to increase to 160.50 million, 44.82 million, and 28.61 million, respectively. Diabetic retinopathy prevalence was highest in Africa (35.90%) and North American and the Caribbean (33.30%) and was lowest in South and Central America (13.37%). In meta-regression models adjusting for habitation type, response rate, study year, and DR diagnostic method, Hispanics (odds ratio [OR], 2.92; 95% CI, 1.22–6.98) and Middle Easterners (OR, 2.44; 95% CI, 1.51–3.94) with diabetes were more likely to have DR compared with Asians. Discussion The global DR burden is expected to remain high through 2045, disproportionately affecting countries in the Middle East and North Africa and the Western Pacific. These updated estimates may guide DR screening, treatment, and public health care strategies.

AimsTo report the 6-year incidence of optical coherence tomography (OCT)-derived age-related changes in drusen volume and related systemic and ocular associations.MethodsChinese adults aged 40 years and older were assessed at baseline and 6 years with colour fundus photography (CFP) and spectral domain (SD) OCT. CFPs were graded for age-related macular degeneration (AMD) features and drusen volume was generated using commercially available automated software.ResultsA total of 4172 eyes of 2580 participants (mean age 58.12±9.03 years; 51.12% women) had baseline and 6-year follow-up CFP for grading, of these, 2130 eyes of 1305 participants had gradable SD-OCT images, available for analysis. Based on CFP grading, 136 (3.39%) participants developed incident early AMD and 10 (0.25%) late AMD. Concurrently, retinal pigment epithelial-Bruch’s membrane (RPE-BrC) volumes decreased, remained stable and increased in 6.8%, 78.5% and 14.7%, respectively, over 6 years. In eyes where RPE-BrC volumes were >0 mm3at baseline, this was associated with two-fold higher prevalence rate of any AMD at baseline (pConclusionAMD incidence detected at 6 years on CFP and correlated OCT-derived drusen volume measurement change is low. Older age and some systemic risk factors are associated with drusen volume change, and our data provide new insights into relationship between systemic risk factors and outer retinal morphology in Asian eyes.

Topic Glaucoma is the leading cause of irreversible blindness, despite having good prognosis with early treatment. We evaluated the global extent of undetected glaucoma and the factors associated with it in this systematic review and meta-analysis. Clinical Relevance Undetected glaucoma increases the risk of vision impairment, which leads to detrimental effects on the quality-of-life and socioeconomic well-being of those affected. Detailed information on the extent and factors associated with undetected glaucoma aid in the development of public health interventions. Methods We conducted a systematic review and meta-analysis of population-based studies published between January 1, 1990, and June 1, 2020. Article search was conducted in online databases (PubMED, Web-of-Science), grey literatures (OpenGrey), and nongovernment organization reports. Our outcome measure was the proportion of glaucoma cases that were undetected previously. Manifest glaucoma included any form of glaucoma reported in the original studies and may include primary open-angle glaucoma (POAG), primary angle-closure-glaucoma, secondary glaucoma, or a combination thereof. Undetected glaucoma was defined as glaucoma cases that were undetected prior to diagnosis in the respective study. Random-effect meta-analysis was used to estimate the pooled proportion of undetected glaucoma. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Meta-analysis of Observational Studies in Epidemiology guidelines in our study. Results We identified 61 articles from 55 population-based studies (n = 189 359 participants; n = 6949 manifest glaucoma). Globally, more than half of all glaucoma cases were undetected previously on average in each geographical region. Africa (odds ratio [OR], 12.70; 95% confidence interval [CI], 4.91–32.86) and Asia (OR, 3.41; 95% CI, 1.63–7.16) showed higher odds of undetected glaucoma as compared with Europe. Countries with low Human Development Index (HDI; Discussion Undetected glaucoma is highly prevalent across diverse communities worldwide and more common in Africa and Asia. Strategies to improve detection are needed to prevent excess visual disability and blindness resulting from glaucoma.

Objective: Age-related macular degeneration(AMD) has become a major cause of visual impairment worldwide, especially in the elderly. Estimates of incidence, progression rates, and risk factors of AMD vary among studies, complicating the understanding of its epidemiology. Methods: For this systematic review and meta-analysis, literature published up to March 1, 2021, was searched in both English and Chinese databases. Hierarchical Bayesian approaches were used to estimate pooled incidence, progression, and 95% credible intervals (CrIs). Results: Thirty studies were included. The pooled annual early and late AMD incidence rates were 1.59 (95% CrI: 1.18–2.11) and 0.23 (95% CrI: 0.14–0.34) per 100 person-years, respectively. The annual progression rate of AMD was 5.5 (95% CrI: 2.3–8.8) per 100 person-years. Smoking was an independent risk factor for both early and late AMD, whereas age, high-density lipoprotein cholesterol, and alcohol consumption were risk factors for early AMD incidence only. The projected number of new cases of early and late AMD in 2050 would be 39.05 million (95% CrI: 23.12–63.57) and 6.41 million (95% CrI: 3.37–13.22), respectively. Conclusion: The prediction the number of new cases of AMD is not equal across the globe. Our findings indicate the need for more rigorous control and prevention measures in AMD focus on its risk factors for early intervention. The epidemiological estimates reported in this study could inform to identify effective strategies for preventing AMD worldwide.

The prominent rise of digital health in ophthalmology is evident in the current age of Industry 4.0. Despite the many facets of digital health, there has been a greater slant in interest and focus on artificial intelligence recently. Other major elements of digital health like wearables could also substantially impact patient-focused outcomes but have been relatively less explored and discussed. In this review, we comprehensively evaluate the use of non-artificial intelligence digital health tools in ophthalmology. 53 papers were included in this systematic review - 25 papers discuss virtual or augmented reality, 14 discuss mobile applications and 14 discuss wearables. Most papers focused on the use of technologies to detect or rehabilitate visual impairment, glaucoma and age-related macular degeneration. Overall, the findings on patient-focused outcomes with the adoption of these technologies are encouraging. Further validation, large-scale studies and earlier consideration of real-world barriers are warranted to enable better real-world implementation.

Topic Visual impairment (VI) and cognitive impairment (CIM) are prevalent age-related conditions that impose substantial burden on the society. Findings on the hypothesized bidirectional association of VI and CIM remains equivocal. Hence, we conducted a systematic review and meta-analysis to examine this bidirectional relationship. Clinical Relevance Sixty percent risk of CIM has not been well elucidated in the literature. A bidirectional relationship between VI and CIM may support the development of strategies for early detection and management of risk factors for both conditions in older people. Methods PubMed, Embase, and Cochrane Central registers were searched systematically for observational studies, published from inception until April 6, 2020, in adults 40 years of age or older reporting objectively measured VI and CIM assessment using clinically validated cognitive screening tests or diagnostic evaluation. Meta-analyses on cross-sectional and longitudinal associations between VI and CIM outcomes (any CIM assessed using screening tests and clinically diagnosed dementia) were examined. Random effect models were used to generate pooled odds ratios (ORs) and 95% confidence intervals (CIs). We also examined study quality, publication bias, and heterogeneity. Results Forty studies were included (n = 47 913 570). Meta-analyses confirmed that persons with VI were more likely to have CIM, with significantly higher odds of: (1) any CIM (cross-sectional: OR, 2.38 [95% CI, 1.84–3.07]; longitudinal: OR, 1.66 [95% CI, 1.46–1.89]) and (2) clinically diagnosed dementia (cross-sectional: OR, 2.43 [95% CI, 1.48–4.01]; longitudinal: OR, 2.09 [95% CI, 1.37–3.21]) compared with persons without VI. Significant heterogeneity was explained partially by differences in age, sex, and follow-up duration. Also, some evidence suggested that individuals with CIM, relative to cognitively intact persons, were more likely to have VI, with most articles (8/9 [89%]) reporting significantly positive associations; however, meta-analyses on this association could not be conducted because of insufficient data. Discussion Overall, our work suggests that VI is a risk factor of CIM, although further work is needed to confirm the association of CIM as a risk factor for VI. Strategies for early detection and management of both conditions in older people may minimize individual clinical and public health consequences.

PurposeTo evaluate the performance of swept source optical coherence tomography (SS-OCT) to detect gonioscopic angle closure using different classification algorithms.MethodsThis was a cross-sectional study of 2028 subjects without ophthalmic symptoms recruited from a community-based clinic. All subjects underwent gonioscopy and SS-OCT (Casia, Tomey Corporation, Nagoya, Japan) under dark room conditions. For each eye, 8 out of 128 frames (22.5° interval) were selected to measure anterior chamber parameters namely anterior chamber width, depth, area and volume (ACW, ACD, ACA, and ACV), lens vault (LV), iris curvature (IC), iris thickness (IT) from 750 µm and 2000 µm from the scleral spur, iris area and iris volume. Five diagnostic algorithms—stepwise logistic regression, random forest, multivariate adaptive regression splines, recursive partitioning and Naïve Bayes were evaluated for detection of gonioscopic angle closure (defined as ≥2 closed quadrants). The performance of the horizontal frame was compared with that of other meridians.ResultsData from 1988 subjects, including 143 (7.2%) with gonioscopic angle closure, were available for analysis. They were divided into two groups: training (1391, 70%) and validation (597, 30%). The best algorithm for detecting gonioscopic angle closure was stepwise logistic regression with an area under the curve of 0.91 (95% CI 0.88 to 0.93) using all parameters, and 0.88 (95% CI 0.82 to 0.93) using only ACA, LV and IC of the horizontal meridian scan.ConclusionsA stepwise logistic regression model incorporating SS-OCT measurements has a high diagnostic ability to detect gonioscopic angle closure.

PURPOSE To examine the association between near work, screen time including TV and outdoor time with myopia in children from the Sunflower Myopia Asian Eye Epidemiology Consortium (AEEC). METHODS We analysed AEEC cross-sectional data (12 241 children) on risk factors (near work, screen time including TV and outdoor time) and myopia of six population-based studies (China, Hong Kong and Singapore). Cycloplegic refraction and axial length (AL) measurements were included. Risk factors were determined using questionnaires. Data were pooled from each study, and multivariable regression analysis was performed to evaluate the associations between risks factors and myopia, spherical equivalent (SE) and AL. RESULTS Among the included children, 52.1% were boys, 98.1% were Chinese and 69.7% lived in urban areas. Mean±standard deviation (SD) for age was 8.8 ± 2.9 years, for SE was -0.14 ± 1.8 D and for AL was 23.3 ± 1.1 mm. Myopia prevalence was 30.6%. In multivariate analysis, more reading and writing (OR = 1.17; 95% CI, 1.11-1.24), more total near work (OR = 1.05; 95% CI, 1.02-1.09) and less outdoor time (OR = 0.82, 95% CI, 0.75-0.88) were associated with myopia (p's

Importance: Uncertainty currently exists about whether the same genetic variants are associated with susceptibility to low myopia (LM) and high myopia (HM) and to myopia and hyperopia. Addressing this question is fundamental to understanding the genetics of refractive error and has clinical relevance for genotype-based prediction of children at risk for HM and for identification of new therapeutic targets. Objective: To assess whether a common set of genetic variants are associated with susceptibility to HM, LM, and hyperopia. Design, Setting, and Participants: This genetic association study assessed unrelated UK Biobank participants 40 to 69 years of age of European and Asian ancestry. Participants 40 to 69 years of age living in the United Kingdom were recruited from January 1, 2006, to October 31, 2010. Of the total sample of 502682 participants, 117279 (23.3%) underwent an ophthalmic assessment. Data analysis was performed from December 12, 2019, to June 23, 2020. Exposures: Four refractive error groups were defined: HM, -6.00 diopters (D) or less; LM, -3.00 to -1.00 D; hyperopia, +2.00 D or greater; and emmetropia, 0.00 to +1.00 D. Four genome-wide association study (GWAS) analyses were performed in participants of European ancestry: (1) HM vs emmetropia, (2) LM vs emmetropia, (3) hyperopia vs emmetropia, and (4) LM vs hyperopia. Polygenic risk scores were generated from GWAS summary statistics, yielding 4 sets of polygenic risk scores. Performance was assessed in independent replication samples of European and Asian ancestry. Main Outcomes and Measures: Odds ratios (ORs) of polygenic risk scores in replication samples. Results: A total of 51841 unrelated individuals of European ancestry and 2165 unrelated individuals of Asian ancestry were assigned to a specific refractive error group and included in our analyses. Polygenic risk scores derived from all 4 GWAS analyses were predictive of all categories of refractive error in both European and Asian replication samples. For example, the polygenic risk score derived from the HM vs emmetropia GWAS was predictive in the European sample of HM vs emmetropia (OR, 1.58; 95% CI, 1.41-1.77; P = 1.54 × 10-15) as well as LM vs emmetropia (OR, 1.15; 95% CI, 1.07-1.23; P = 8.14 × 10-5), hyperopia vs emmetropia (OR, 0.83; 95% CI, 0.77-0.89; P = 4.18 × 10-7), and LM vs hyperopia (OR, 1.45; 95% CI, 1.33-1.59; P = 1.43 × 10-16). Conclusions and Relevance: Genetic risk variants were shared across HM, LM, and hyperopia and across European and Asian samples. Individuals with HM inherited a higher number of variants from among the same set of myopia-predisposing alleles and not different risk alleles compared with individuals with LM. These findings suggest that treatment interventions targeting common genetic risk variants associated with refractive error could be effective against both LM and HM..

Purpose To describe the distribution and determinants of choroidal thickness (CT) in participants in a population study based on spectral-domain (SD)-OCT measurements. Design Population-based, cross-sectional study. Participants Ethnic Chinese, Indian, and Malay adults aged more than 50 years without any retinal diseases (e.g., diabetic retinopathy, macular edema, age-related macular degeneration, central serous chorioretinopathy) that might affect the CT were recruited from the Singapore Epidemiology of Eye Diseases Study. Methods Choroidal imaging was performed by SD-OCT (Spectralis, Heidelberg Engineering, Heidelberg, Germany) in enhanced depth imaging (EDI) mode. Subfoveal choroidal thickness (SFCT) was measured on the foveal line scan by 2 retinal experts independently (YS and KT), and the average was used in the analyses. In Chinese and Indian cohorts in whom macular raster scans were captured, the manufacturer-supplied research software (Heyex SP-X version 6.4.8.116; Heidelberg Engineering) was used to obtain automated segmentation yielding mean choroidal thickness in each of the 9 ETDRS grid sectors. Main Outcome Measures Subfoveal choroidal thickness and regional CT in the 9 ETDRS grid sectors. Results For the SFCT analysis, 2794 eyes of 1619 participants (Chinese, Indian, and Malay ) were included. The mean age was 60.9 years (standard deviation, 7.7), and 797 (49.2%) were male. Mean SFCT was 255.2 μm (standard deviation, 102.6). The normal range of SFCT was 106 to 447 μm (corresponding to 5th and 95th percentile limits of SFCT, respectively). In multivariable models, thinner SFCT was associated with older age, female gender, longer axial length, and Malay (vs. Chinese) ethnicity. In the subset of Chinese and Indian eyes (n = 1842) in whom regional variation was evaluated, the choroid was thickest at the superior and temporal sectors and thinner at the inferior and nasal sectors. Conclusions Subfoveal choroidal thickness is influenced by age, gender, and ethnicity along with regional differences even within individual eyes. Subfoveal choroidal thickness also shows a wide range in physiologic limits. These data may be used as a reference in future studies.

AimsTo characterise the association between visual field (VF) defects and myopic macular degeneration (MMD) in highly myopic adults without glaucoma.MethodsParticipants (n=106; 181 eyes) with high myopia (HM; spherical equivalent ≤−5.0 D or axial length (AL) ≥26 mm), after excluding glaucoma and glaucoma suspects, from the Singapore Epidemiology of Eye Diseases-HM study were included in this cross-sectional study. Humphrey VF (central 24–2 threshold), cup-disc ratio (CDR) and intraocular pressure (IOP) measurements were performed. Mean deviation (MD) and pattern SD (PSD), VF defects (normal or abnormal; pResultsMean age was 55.4±9.9 years and 51.9% were women (AL=26.7±1.1 mm). MMD eyes had lower MD (−3.8±2.9 dB vs −1.1±1.4 dB) and higher PSD (2.8±1.7 dB vs 1.7±0.6 dB). A higher percentage of MMD eyes (n=48) had abnormal VF (62.5% vs 28.6%; pConclusionHighly myopic adults with MMD may have VF loss when compared with highly myopic patients without MMD even in adults without glaucoma.

When fire disasters are imminent, disaster prevention measures and relief plans are critical. However, “fire education” to equip civilians with the know-how to cope with various emergencies and protect themselves is perhaps more important. To provide learning materials which are interesting, appealing, flexible, safe, and efficient for fire education, this study adopts an augmented reality (AR) technique to create an interactive fire education learning environment. This study constructs an interactive learning environment for fire education and examines the learning effectiveness between an AR card and tangible-user-interface-based (TUI) AR in motivation, fire prevention attitude, and cognitive learning outcome. In the proposed AR interactive learning environment, Kolb’s experiential learning cycle is used to guide students’ learning process. There were 170 experimental participants in this study; 86 were assigned to the experimental group using the TUI, and 84 to the control group using AR cards. The AR system integrated with experiential learning could improve students’ fire prevention attitudes and learning outcomes in both groups. Moreover, the experimental group performed better in the cognitive learning outcome and had lower mental loads than the control group. However, no difference in the fire prevention attitude between the two groups was found. In other words, the “object-linked” characteristics provided by TUI-AR benefits cognitive performance rather than attitude. To conclude, this research presents an important perspective on the introduction of technology into fire education that contributes to the broader body of teaching and learning on school fire education.

To determine the 6-year incidence of primary glaucoma and its risk factors in an Indian population in Singapore.Cohort population-based study.Indian adults between 40 and 80 years of age living in Singapore. A total of 3400 participants underwent the baseline examination between 2007 and 2009. Of them, 2200 (response rate, 75.5% of those eligible) participated in the 6-year follow-up visit between 2013 and 2015.Standardized examination and investigations were performed, including indentation gonioscopy, intraocular pressure (IOP) measurement, optic disc examination, and static automated perimetry. Glaucoma was defined according to the International Society Geographical and Epidemiological Ophthalmology criteria.Incidences of primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG).The age-standardized incidences of primary glaucoma, POAG, and PACG were 1.68% (95% confidence interval [CI], 1.21%-2.32%), 1.37% (95% CI, 0.94%-1.96%), and 0.32% (95% CI, 0.15%-0.66%), respectively. For eyes with ocular hypertension (n = 45) at baseline, the incidence of POAG was 4.83% (95% CI, 1.24%-17.21%) and for eyes with primary angle closure (n = 14) or suspected primary angle closure (n = 101), the incidence of PACG developing was 1.82% (95% CI, 0.37%-9.68%). Baseline factors associated significantly with risk of primary glaucoma developing included older age (per decade; odds ratio [OR], 1.84; 95% CI, 1.44-2.36; P0.001), larger vertical cup-to-disc ratio (per 0.1 unit; OR, 2.78; 95% CI, 2.12-3.64; P0.001), and higher IOP (per millimeter of mercury; OR, 1.25; 95% CI, 1.13-1.38; P0.001). However, 71 of 85 eyes (84.5%) diagnosed with incident glaucoma had IOP of less than 21 mmHg at the time of examination.Our study showed that the overall age-standardized incidence of primary glaucoma was 1.68% in an Indian population in Singapore. In our population, the incidence of POAG was only half and the incidence of PACG was similar to the incidence reported by the Chennai Eye Disease Study.

Purpose Visual impairment (VI) can have a detrimental impact on vision-related quality of life (VRQoL), but it is still unclear how this relationship varies with age across the VI spectrum. We determined the age-stratified, cross-sectional, and longitudinal associations between VI severity and VRQoL. Design The baseline and follow-up Singapore Chinese Eye Studies (SCES-1/-2; 2009–2011 and 2015–2017). Participants A total of 3068 SCES-1 participants (mean age [standard deviation {SD}]: 59.5 [9.8] years; 50.2% female) and 1919 SCES-2 participants (mean age [SD]: 56.8 [8.3] years; 49.9% female). Methods Visual impairment was defined as visual acuity (VA) of > 0.3 logarithm of the minimum angle of resolution (logMAR) units; VI severity as mild-moderate (logMAR scores less than the median of all individuals with VI) and severe (logMAR scores median or greater); and VI incidence as VI absence at baseline, but evident at follow-up. Age was stratified into 40 to 49 years, 50 to 64 years, and ≥65 years. Main Outcome Measures Rasch-transformed scores from the 32-item Impact of Visual Impairment (IVI) questionnaire were used to measure the “Reading,” “Mobility,” and “Emotional” domains of VRQoL. Multiple linear regression models determined the age-stratified associations of prevalent and incident VI with all 3 VRQoL outcomes, adjusted for potential confounders. Results Of the 807 persons with prevalent VI, 55.9% had mild-moderate and 44.1% had severe VI. Compared with no VI, age-stratified analyses showed that VRQoL decrements were significant only in the older age groups (mild-moderate VI: 6.2% and 8.1% reduction in Mobility and Reading scores in those aged ≥ 65 years; severe VI: 8.5% to 13.4% reductions in the 3 VRQoL scores in those aged ≥ 50 years). This interaction with older age became more pronounced with incident VI (N = 168), where decrements in all 3 VRQoL domains were evident only in those aged ≥65 years compared with persons without incident VI. Conclusions Our results suggest that the VI-VRQoL associations are driven mainly by older individuals aged ≥65 years, highlighting the need for effective regular screening and early intervention modalities to prevent the presence and onset of VI, and subsequent VRQoL declines, in these individuals.

To investigate whether recently identified genetic loci for primary angle-closure glaucoma (PACG) are associated with disease severity.Case-control study.Eight hundred four PACG patients and 943 control participants of Chinese ethnicity from Singapore.The 8 PACG-associated single nucleotide polymorphisms (SNPs; rs11024102 at PLEKHA7, rs3753841 at COL11A1, rs1015213 located between PCMTD1 and ST18 on chromosome 8q, rs3816415 at EPDR1, rs1258267 at CHAT, rs736893 at GLIS3, rs7494379 at FERMT2, and rs3739821 mapping in between DPM2 and FAM102A) identified from genome-wide association studies were tested for association with disease severity using logistic regression adjusted for age and gender. A P value of 0.006 was set as significant after Bonferroni correction for testing of 8 loci. We also calculated the weighted genetic risk score (GRS) weighted by the estimated individual SNP effect size on PACG calculated as logarithm of the odds ratio (OR). Disease severity was based on the visual field mean deviation (MD) and classified as early to moderate (MD,-12 dB) and severe (MD,-20 dB).Association of PACG loci with severe disease.Of the 804 PACG patients, genotyping data were available for 768 individuals and included 436 with mild-to-moderate PACG and 206 with severe PACG. The PACG patients were significantly older (mean age, 64.3 ± 9.1 years vs. 56.4 ± 8.9 years; P0.001) and there were proportionately more women compared with control participants (58.4% vs. 49.0%; P0.001). Of the 8 loci investigated, we observed significant evidence of association with severe PACG at 1 SNP, namely rs3816415 in EPDR1 (OR, 2.03; 95% confidence interval [CI], 1.49-2.78; P = 1 × 10Our results show that EPDR1 is associated significantly with severe PACG, suggesting that it may predispose patients to more aggressive disease development. Individuals with PACG with a higher GRS were associated with a higher risk of severe PACG.

Objective To report two cases of for primary peritoneal serous carcinoma (PPSC) to present with gastrointestinal manifestations that mimic colorectal cancer. Case report There were two patients with initial presentations of fatigue with iron deficiency anemia, and tenesmus with bloody stool. Tumors of the ascending colon and rectum were detected by colonofiberoscope, and pathologic reports of tumor biopsies revealed adenocarcinoma of suspected gynecologic origin. Both patients underwent optimal debulking surgery without macroscopic residual tumor, and then received adjuvant carboplatin and paclitaxel chemotherapy with bevacizumab. Conclusions PPSC can clinically present like primary colorectal carcinoma. The differential diagnosis requires special staining of several markers for tumor tissues.

Previously, variation in retinal vascular caliber has been reported in association with chronic kidney disease (CKD) but findings remain inconsistent. To help clarify this we conducted individual participant data meta-analysis and aggregate data meta-analysis on summary estimates to evaluate cross-sectional associations between retinal vascular caliber and CKD. A systematic review was performed using Medline and EMBASE for articles published until October 2018. The aggregate analysis used a two-stage approach combining summary estimates from eleven studies (44,803 patients) while the individual participant analysis used a one-stage approach combining raw data from nine studies (33,222 patients). CKD stages 3-5 was defined as an estimated glomerular filtration rate under 60 mL/min/1.73m2. Retinal arteriolar and venular caliber (central retinal arteriolar and venular equivalent) were assessed from retinal photographs using computer-assisted methods. Logistic regression estimated relative risk of CKD stages 3-5 associated with a 20 μm decrease (approximately one standard deviation) in central retinal arteriolar and venular equivalent. Prevalence of CKD stages 3-5 was 11.2% of 33,222 and 11.3% of 44,803 patients in the individual participant and aggregate data analysis, respectively. No significant associations were detected in adjusted analyses between central retinal arteriolar and venular equivalent and CKD stages 3-5 in the aggregate analysis for central retinal arteriolar relative risk (0.98, 95% confidence interval 0.94-1.03); venular equivalent (0.99, 0.95-1.04) or individual participant central retinal arteriolar (0.99, 0.95-1.04) or venular equivalent (1.01, 0.97-1.05). Thus, meta-analysis provided little evidence to suggest that cross sectional direct measurements of retinal vascular caliber was associated with CKD stages 3-5 in the general population. Hence, meta-analyses of longitudinal studies evaluating the association between retinal parameters and CKD stages 3-5 may be warranted.

Background/aimsObesity is a well-known risk factor for diabetes, but its association with diabetic retinopathy (DR) is inconclusive, in particular in Asians. We aimed to assess whether body mass index (BMI) is associated with the presence and severity of DR in Asian populations with diabetes.MethodsPooled analysis of individual-level cross-sectional data from 10 010 adults with diabetes who participated in 12 population-based studies conducted in China, India, Japan, Russia (Asian), Singapore and South Korea that were part of the Asian Eye Epidemiology Consortium (AEEC). BMI was calculated as weight in kilograms divided by height in square metres and categorised into normal (2, reference), overweight (25–29.9 kg/m2) and obese (≥30 kg/m2). Any-DR (n=1669) and vision-threatening DR (VTDR, n=489) were assessed from digital retinal photographs and graded according to standard protocols. Each study was analysed separately using multivariable logistic regression models adjusted for age, sex, haemoglobin A1c%, systolic blood pressure and diabetes duration, and the estimated odds ratios (ORs) and 95% confidence interval (CIs) from all studies were then combined using random-effects models.ResultsIn multivariable models, obesity showed a significant inverse association with any-DR (pooled OR (95% CI) =0.74 (0.59 to 0.91)) and VTDR (0.75 (0.60 to 0.93)). Similarly, in continuous analysis, BMI showed a significant inverse association with both any-DR (0.93 (0.87 to 0.99)) and VTDR (0.79 (0.68 to 0.92) per SD increase). Overweight did not show a significant association with any-DR.ConclusionsAmong Asian adults with diabetes, both BMI and obesity showed an inverse association with DR. These findings warrant confirmation in further longitudinal studies.

PurposeTo evaluate the effect of signal strength (SS) on optical coherence tomography (OCT) parameters, and devise an algorithm to adjust the effect, when acceptable SS cannot be obtained.Methods5085 individuals (9582 eyes), aged ≥40 years from the Singapore Epidemiology of Eye Diseases population-based study were included. Everyone underwent a standardised ocular examination and imaging with Cirrus HD-OCT. Effect of SS was evaluated using multiple structural breaks linear mixed-effect models. Expected change for increment in SS between 4 and 10 for individual parameter was calculated. Subsequently we devised and evaluated an algorithm to adjust OCT parameters to higher SS.ResultsAverage retinal nerve fibre layer (RNFL) thickness showed shift of 4.11 µm from SS of 5 to 6. Above 6, it increased by 1.72 and 3.35 µm to 7 and 8; and by 1.09 µm (per unit increase) above 8 SS. Average ganglion cell-inner plexiform layer (GCIPL) thickness shifted 5.15 µm from SS of 5 to 6. Above 6, increased by 0.94 µm from 7 to 8; and by 0.16 µm (per unit increase) above 8 SS. When compared with reference in an independent test set, the algorithm produced less systemic bias. Algorithm-adjusted average RNFL was 0.549 µm thinner than the reference, while the unadjusted one was 2.841 µm thinner (pConclusionsOCT parameters can be adjusted for poor SS using an algorithm. This can potentially assist in diagnosis and monitoring of glaucoma when scans with acceptable SS cannot be acquired from patients in clinics.

Objective: The impact of white matter hyperintensities (WMH) on language possibly depends on lesion location through disturbance of strategic white matter tracts. We examined the impact of WMH location on language in elderly Asians. Design: Cross-sectional. Setting: Population-based. Participants: Eight-hundred nineteen residents of Singapore, ages (≥65 years). Measurements: Clinical, cognitive and 3T magnetic resonance imaging assessments were performed on all participants. Language was assessed using the Modified Boston Naming Test (MBNT) and Verbal Fluency (VF). Hypothesis-free region-of-interest-based (ROI) analyses based on major white matter tracts were used to determine the association between WMH location and language. Conditional dependencies between the regional WMH volumes and language were examined using Bayesian-network analysis. Results: ROI-based analyses showed that WMH located within the anterior thalamic radiation (mean difference: −0.12, 95% confidence interval [CI]: −0.22; −0.02, p = 0.019) and uncinate fasciculus (mean difference: −0.09, 95% CI: −0.18; −0.01, p = 0.022) in the left hemisphere were significantly associated with worse VF but did not survive multiple testing. Conversely, WMH volume in the left cingulum of cingulate gyrus was significantly associated with MBNT performance (mean difference: −0.09, 95% CI: −0.17; −0.02, p = 0.016). Bayesian-network analyses confirmed the left cingulum of cingulate gyrus as a direct determinant of MBNT performance. Conclusion: Our findings identify the left cingulum of cingulate gyrus as a strategic white matter tract for MBNT, suggesting that language – is sensitive to subcortical ischemic damage. Future studies on the role of sporadic ischemic lesions and vascular cognitive impairment should not only focus on total WMH volume but should also take WMH lesion location into account when addressing language.

Background The relationship between self-reported visual disability and cognitive impairment in older individuals is unclear. Objective To determine the relationship of vision-specific functioning (VSF), vision-specific mobility (VSM) and visual acuity (VA) with clinically assessed cognitive impairment in the Epidemiology of Dementia in Singapore study. Design Cross-sectional. Setting Population-based. Subjects Eight hundred and seventy-four adults aged ≥60 years at higher risk of possible cognitive impairment by the Abbreviated Mental Test and progressive forgetfulness question. Methods VSF and VSM were measured using Rasch-transformed continuous scores of two Impact of Vision Impairment questionnaire domains. Cognitive impairment was objectively determined using detailed neuropsychological testing and defined as no cognitive impairment (NCI), mild cognitive impairment-no dementia (CIND), moderate CIND only and moderate CIND or dementia. Associations were assessed using multinomial logistic regression models. Results Of the 874 participants (49.0% males, mean age (SD) 65.5 (7.0) years), 277, 281 and 316 had NCI, mild CIND and moderate CIND or dementia, respectively. Compared to NCI, the odds of moderate CIND, and moderate CIND or dementia increased for every SD worsening in VSF (OR: 1.44, 95% CI 1.14–1.82, and OR: 1.52, 95%CI 1.19–1.94, respectively) and VSM (OR: 1.42, 95%CI 1.11–1.81, and OR: 1.50, 95%CI 1.15–1.95). Similarly, the odds of mild CIND (OR: 1.62, 95%CI 1.19–2.22), moderate CIND (OR: 1.93, 95%CI 1.45–2.58), and moderate CIND or dementia (OR: 2.25, 95%CI 1.62–3.11) increased significantly with every SD worsening of VA. Conclusions Our results emphasise the importance of interventions to prevent vision loss and improve quality of life to reduce likelihood of age-related cognitive decline.

PurposeWe described the 6-year incidence and changes of retinopathy, and their associated risk factors in a multi-ethnic Asian population without diabetes.MethodsWe included 4374 participants with non-diabetes from a population-based cohort, the Singapore Epidemiology of Eye Disease Study, with gradable retinal photographs at baseline and 6-year follow-up visit. Retinopathy was assessed according to the modified Airlie House classification system.ResultsOver the 6-year period, the cumulative rates were 2.5% (106/4279) for retinopathy incidence, 1.0% (1/95) for retinopathy progression and 68.4% (65/95) for retinopathy regression. In multivariable analysis, higher diastolic blood pressure (DBP) (risk ratio (RR)=1.02; 95% CI: 1.00 to 1.04; per 10 mm Hg increase in DBP) and wider retinal arteriolar calibre (RR=1.36; 95% CI: 1.13 to 1.63; per SD increase in central retinal artery equivalent) were associated with higher risk of incident retinopathy, while higher level of high-density lipoprotein (HDL) was associated with lower risk of incident retinopathy (RR=0.56; 95% CI: 0.32 to 0.99; per mmol/L increase in HDL). Compared with Chinese, Malays were more likely to have retinopathy regression (RR=1.63; 95% CI: 1.20 to 2.22), while overweight (RR=0.47; 95% CI: 0.26 to 0.84) and higher glycosylated haemoglobin (HbA1c) level (RR=0.58; 95% CI: 0.37 to 0.93; per per cent increase in HbA1c) were associated with lower likelihood of retinopathy regression.ConclusionRisk of developing retinopathy in Asians without diabetes is generally low. However, regression of retinopathy over time is common, suggesting that these retinopathy signs may reflect subclinical reversible microvascular dysfunction. Several metabolic risk factors are associated with incidence or regression of retinopathy, suggesting that good metabolic control may still be important in the management of non-diabetic retinopathy.

AimsTo compare the shape of the anterior surface of the peripapillary sclera (PPS) between glaucoma and healthy subjects.Methods88 primary open angle glaucoma (POAG), 98 primary angle closure glaucoma (PACG) and 372 age-matched and gender-matched healthy controls were recruited in this study. The optic nerve head of one randomly selected eye of each subject was imaged with spectral domain optical coherence tomography. The shape of the PPS was measured through an angle defined between a line parallel to the nasal anterior PPS boundary and one parallel to the temporal side. A negative value indicated that the PPS followed an inverted v-shaped configuration (peak pointing towards the vitreous), whereas a positive value indicated that it followed a v-shaped configuration.ResultsThe mean PPS angle in normal controls (4.56±5.99°) was significantly smaller than that in POAG (6.60±6.37°, p=0.011) and PACG (7.90±6.87°, pConclusionsThe v-shaped configuration of the PPS was more pronounced in glaucoma eyes than in healthy eyes. This posterior bowing of the PPS may have an impact on the biomechanical environment of the optic nerve head.

Nuclear cataract is the most common type of age-related cataract and a leading cause of blindness worldwide. Age-related nuclear cataract is heritable (h2 = 0.48), but little is known about specific genetic factors underlying this condition. Here we report findings from the largest to date multi-ethnic meta-analysis of genome-wide association studies (discovery cohort N = 14,151 and replication N = 5299) of the International Cataract Genetics Consortium. We confirmed the known genetic association of CRYAA (rs7278468, P = 2.8 × 10−16) with nuclear cataract and identified five new loci associated with this disease: SOX2-OT (rs9842371, P = 1.7 × 10−19), TMPRSS5 (rs4936279, P = 2.5 × 10−10), LINC01412 (rs16823886, P = 1.3 × 10−9), GLTSCR1 (rs1005911, P = 9.8 × 10−9), and COMMD1 (rs62149908, P = 1.2 × 10−8). The results suggest a strong link of age-related nuclear cataract with congenital cataract and eye development genes, and the importance of common genetic variants in maintaining crystalline lens integrity in the aging eye., Here, the authors report a multi-ethnic genome wide association meta-analysis of 12 studies from the International Cataract Genetics Consortium. They find six new loci associated with age-related nuclear cataract, in addition to replicating the association at CRYAA, and suggest a strong genetic link between age-related nuclear and congenital cataracts.

Purpose To identify novel susceptibility loci for high myopia. Design Genome-wide association study (GWAS) followed by replication and meta-analysis. Participants A total of 14 096 samples from East and Southeast Asian populations (2549 patients with high myopia and 11 547 healthy controls). Methods We performed a GWAS in 3269 Japanese individuals (1668 with high myopia and 1601 control participants), followed by replication analysis in a total of 10 827 additional samples (881 with high myopia and 9946 control participants) from Japan, Singapore, and Taiwan. To confirm the biological role of the identified loci in the pathogenesis of high myopia, we performed functional annotation and Gene Ontology (GO) analyses. Main Outcome Measures We evaluated the association of single nucleotide polymorphisms with high myopia and GO terms enriched among genes identified in the current study. Results We identified 9 loci with genome-wide significance (P Conclusions The current study identified 6 novel loci associated with high myopia and demonstrated an important role of the nervous system in the disease pathogenesis. Our findings give new insight into the genetic factors underlying myopia, including high myopia, by connecting previous findings and allowing for a clarified interpretation of the cause and pathophysiologic features of myopia at the molecular level.

AimsTo use machine learning (ML) to determine the relative contributions of modifiable and non-modifiable clinical, metabolic, genetic, lifestyle and socioeconomic factors on the risk of major eye diseases.MethodsWe conducted analyses in a cross-sectional multi-ethnic population-based study (n=10 033 participants) and determined a range of modifiable and non-modifiable risk factors of common eye diseases, including diabetic retinopathy (DR), non-diabetic-related retinopathy (NDR); early and late age-related macular degeneration (AMD); nuclear, cortical and posterior subcapsular (PSC) cataract; and primary open-angle (POAG) and primary angle-closure glaucoma (PACG). Risk factors included individual characteristics, metabolic profiles, genetic background, lifestyle patterns and socioeconomic status (n~100 risk factors). We used gradient boosting machine to estimate the relative influence (RI) of each risk factor.ResultsAmong the range of risk factors studied, the highest contributions were duration of diabetes for DR (RI=22.1%), and alcohol consumption for NDR (RI=6.4%). For early and late AMD, genetic background (RI~20%) and age (RI~15%) contributed the most. Axial length was the main risk factor of PSC (RI=30.8%). For PACG, socioeconomic factor (mainly educational level) had the highest influence (20%). POAG was the disease with the highest contribution of modifiable risk factors (cumulative RI~35%), followed by PACG (cumulative RI ~30%), retinopathy (cumulative RI between 20% and 30%) and late AMD (cumulative RI ~20%).ConclusionThis study illustrates the utility of ML in identifying factors with the highest contributions. Risk factors possibly amenable to interventions were intraocular pressure (IOP) and Body Mass Index (BMI) for glaucoma, alcohol consumption for NDR and levels of HbA1c for DR.

Introduction The worldwide coronavirus disease 2019 pandemic re-emphasises the importance of videoconferencing in supporting interactions between nursing home residents and their family and friends. However, there is a scarcity of comparative studies on how modalities of conferencing programs impact health outcomes. The purpose of this study was to compare laptop-based with smartphone-based videoconferencing programs on nursing home residents’ perceptions of loneliness, depressive symptoms and social support. Methods This retrospective secondary analysis used data from two previous studies on the effectiveness of videoconferencing programs (laptop-based and smartphone-based) to improve outcomes of loneliness, depressive symptoms and social support (type and source) among nursing home residents. Generalised estimating equations compared differences from baseline measures with measures at 1 and 3 months between the two groups with and without adjusting for the effects of confounding variables. Results With the exception of age, there were no differences in demographics between participants in the laptop and smartphone groups. Neither changes from baseline in mean scores for loneliness nor depressive symptoms differed between groups. However, changes in mean scores from baseline between groups were significantly greater in the smartphone-based group compared with the laptop-based group for three types of social support: informational and appraisal at 1 and 3 months; and emotional at 3 months. Changes from baseline in mean scores for social support from friends (at 1 and 3 months) and other sources (at 3 months) were also significantly greater for the smartphone group compared with the laptop group. Discussion The two modalities of videoconferencing did not differ in effects on depressive symptoms or loneliness. However, smartphones had a greater effect on the type and source of social support compared with laptops. Whether the small screen of a smartphone reduces users’ anxiety and allows them to talk more on screen is worth studying.

Retinal blood vessels provide information on the risk of cardiovascular disease (CVD). Here, we report the development and validation of deep-learning models for the automated measurement of retinal-vessel calibre in retinal photographs, using diverse multiethnic multicountry datasets that comprise more than 70,000 images. Retinal-vessel calibre measured by the models and by expert human graders showed high agreement, with overall intraclass correlation coefficients of between 0.82 and 0.95. The models performed comparably to or better than expert graders in associations between measurements of retinal-vessel calibre and CVD risk factors, including blood pressure, body-mass index, total cholesterol and glycated-haemoglobin levels. In retrospectively measured prospective datasets from a population-based study, baseline measurements performed by the deep-learning system were associated with incident CVD. Our findings motivate the development of clinically applicable explainable end-to-end deep-learning systems for the prediction of CVD on the basis of the features of retinal vessels in retinal photographs. Deep-learning models for the automated measurement of retinal-vessel calibre in retinal photographs perform comparably to or better than expert graders in associations of measurements of retinal-vessel calibre with cardiovascular risk factors.

Purpose Although there have been many population-based studies of age-related macular degeneration (AMD), only limited information is available in Asia on the epidemiology of geographic atrophy (GA). We aimed to determine the prevalence and patterns of GA through an analysis of multiple studies conducted within the Asian Eye Epidemiology Consortium (AEEC). Design Cross-sectional meta-analyses. Participants A total of 97 213 individuals aged 40 years and older. Methods Data from 22 population-based studies from countries belonging to the AEEC were included. In all studies, AMD was defined on the basis of standardized grading systems. Geographic atrophy was defined as an area of pallor in the fundus with visibility of the underlying choroidal blood vessels and sharply defined borders. Random-effects meta-analysis was performed to estimate overall and age-, gender-, and region-specific pooled prevalence of GA. Main Outcome Measures Prevalence of GA per 1000 persons. Results The mean age was 60.8 ± 10.0 years, and 42 673 (43.9%) were male. Overall, a total of 223 individuals (0.2%) had GA. The pooled overall prevalence of GA was 1.57 per 1000 persons (95% confidence interval [CI], 1.04–2.10), which was 3 times less than that of neovascular AMD of 5.20 per 1000 persons (95% CI, 3.97–6.43). Compared with those aged 50 to 59 years, the prevalence of GA increased from 0.34 per 1000 persons (95% CI, 0.07–0.62) to 2.90 per 1000 persons (95% CI, 1.55–4.25) in those aged ≥70 years. The GA prevalence per 1000 persons was similar between urban (2.22; 95% CI, 1.22–3.23) and rural residents (1.33; 95% CI, 0.70–1.96). Geographic atrophy was more prevalent in South Asia (based on studies from India and Nepal, 3.82 per 1000 persons; 95% CI, 1.72–5.93) compared with East Asia (based on studies from China, Korea, Hong Kong, Taiwan, and Japan, and the Singapore Chinese Eye Study, 0.76 per 1000 persons; 95% CI, 0.31–1.22, P = 0.005). Conclusions Geographic atrophy is uncommon in Asian populations compared with those of European ancestry. Even within Asia, geographic differences in GA prevalence were seen. The findings of this meta-analysis suggest that better dissection of risk factors in the Asian population for GA may provide insights into the biological pathways that drive these late-stage manifestations, thus suggesting better targets for prevention.

AimsTo determine the prevalence and predictors of myopic macular degeneration (MMD) in a consortium of Asian studies.MethodsIndividual-level data from 19 885 participants from four population-based studies, and 1379 highly myopic participants (defined as axial length (AL) >26.0 mm) from three clinic-based/school-based studies of the Asian Eye Epidemiology Consortium were pooled. MMD was graded from fundus photographs following the meta-analysis for pathologic myopia classification and defined as the presence of diffuse choroidal atrophy, patchy chorioretinal atrophy, macular atrophy, with or without ‘plus’ lesion (lacquer crack, choroidal neovascularisation or Fuchs’ spot). Area under the curve (AUC) evaluation for predictors was performed for the population-based studies.ResultsThe prevalence of MMD was 0.4%, 0.5%, 1.5% and 5.2% among Asians in rural India, Beijing, Russia and Singapore, respectively. In the population-based studies, older age (per year; OR=1.13), female (OR=2.0), spherical equivalent (SE; per negative diopter; OR=1.7), longer AL (per mm; OR=3.1) and lower education (OR=1.9) were associated with MMD after multivariable adjustment (all pConclusionIn this pooled analysis of multiple Asian studies, older age, female, lower education, greater myopia severity and longer AL were risk factors of MMD, and myopic SE was the strongest single predictor of MMD.

Although the impact of vision-related quality of life (VRQoL) is assessed optimally using binocular visual acuity (VA), uniocular VA remains the preferred measurement method in clinic-based and epidemiologic studies. We compared the impact of distance presenting binocular VA and uniocular VA in the better-seeing (better-eye VA) and worse-seeing (worse-eye VA) eye on VRQoL.The Singapore Chinese Eye Study 2 (2015-2017), a population-based, cross-sectional study.One thousand eight hundred twenty-two individuals (mean age, 66.2 years [standard deviation, 8.9 years]; 51.1% women) were included.Presenting uniocular VA and binocular VA were assessed using a logarithm of the minimum angle of resolution number chart at a distance of 4 m under standard lighting by trained and certified study optometrists. Multiple linear regression models were constructed to determine the independent associations between binocular VA, better-eye VA, and worse-eye VA and the outcome (VRQoL), adjusted for potential confounders, including age, gender, socioeconomic status, and presence of comorbidities. In addition, a cluster sandwich estimator was used to determine if any differences in β estimates between the associations were statistically significant.Vision-related quality of life was measured using Rasch-transformed scores from the emotional, mobility, and reading domains of the Impact of Visual Impairment (IVI) questionnaire.Although every 2-line increase (worsening) in binocular VA and uniocular VA was associated independently with decrements in emotional, mobility, and reading IVI scores (P0.05 for all), the reductions in all VRQoL domains were substantially lower (P0.1) when using either the better-eye VA (compared with binocular VA β-estimates, -27.8%, -19.4%, and -24.2% difference in emotional, mobility, and reading IVI scores, respectively) or worse-eye VA (compared with binocular VA β estimates, -38.9%, -58.1%, and -57.5% reduction in emotional, mobility, and reading IVI scores, respectively) to quantify vision loss.Uniocular VA seems to underestimate the impact of vision loss on VRQoL indices compared with binocular VA. Our data suggest that researchers, clinicians, and policy planners should consider using binocular instead of uniocular measures of VA in patient-reported outcome evaluation of vision loss because it may better reflect its impact on VRQoL.

To compare the diagnostic ability of macular intraretinal layer thickness with circumpapillary retinal nerve fiber layer (cpRNFL) thickness, either when used individually or in combination with cpRNFL for detecting early, moderate, and advanced glaucoma.Cross-sectional study.A total of 423 glaucoma participants and 423 age- and gender-matched normal participants.Participants underwent Cirrus spectral-domain OCT (SD-OCT) imaging (Carl Zeiss Meditec, Dublin, CA) using the optic disc and macular scanning protocols. Iowa Reference Algorithms (version 3.8.0) were used for intraretinal layer segmentation, and mean thickness of intraretinal layers was rescaled with magnification correction using axial length value. Thickness measurements of each layer/sector and their corresponding areas under the receiver operating characteristic curve (AUCs) were obtained. Glaucoma eyes were subdivided based on of their visual field severity (early, n = 234; moderate, n = 107; advanced, n = 82).Intraretinal layers.Some 67% of participants were male, their average ± standard deviation age was 65±9 years. Circumpapillary retinal nerve fiber layer, macular ganglion cell layer (mGCL), and macular inner plexiform layer (mIPL) were significantly thinner in the glaucoma groups (P0.0005). The 2 best parameters for detecting normal eyes from early glaucoma was cpRNFL (AUC = 0.861) and mGCL (AUC = 0.842), from moderate glaucoma was mGCL combined with inner plexiform layer (IPL) (AUC = 0.915) and cpRNFL (AUC = 0 .914), and from advanced glaucoma was mGCL-IPL (AUC = 0.984) and cpRNFL (AUC = 0.977). There was no statistical significance between AUCs for the macular parameter and cpRNFL thickness measurement at any of the severities (P0.05). Combining macular and cpRNFL parameters improved the diagnostic performance for early glaucoma (AUC = 0.908; P = 0.002) and moderate glaucoma (AUC = 0.944; P = 0.031) but not for advanced glaucoma (AUC = 0.991; P0.05).Single-layer mGCL thickness is comparable to the traditional cpRNFL thickness for the diagnosis of early/moderate glaucoma, whereas cpRNFL thickness remains the most efficient for advanced glaucoma. Combining macular measurements (GCL and GCL-IPL) and cpRNFL improved the discrimination of early/moderate glaucoma but not of advanced glaucoma. For the diagnosis of early glaucoma, both macular and optic disc scans should be used.

Big data is the fuel of mankind's fourth industrial revolution. Coupled with new technology such as artificial intelligence and deep learning, the potential of big data is poised to be harnessed to its maximal in years to come. In ophthalmology, given the data-intensive nature of this specialty, big data will similarly play an important role. Electronic medical records, administrative and health insurance databases, mega national biobanks, crowd source data from mobile applications and social media, and international epidemiology consortia are emerging forms of "big data" in ophthalmology. In this review, we discuss the characteristics of big data, its potential applications in ophthalmology, and the challenges in leveraging and using these data. Importantly, in the next phase of work, it will be pertinent to further translate "big data" findings into real-world applications, to improve quality of eye care, and cost-effectiveness and efficiency of health services in ophthalmology.

IMPORTANCE Long-term data on age-related cataract, a leading cause of blindness and visual impairment, is scarce in Asian populations. BACKGROUND We report the 6-year incidence and progression of age-related cataract and associated risk factors in Malay adults living in Singapore. DESIGN Population-based cohort study. PARTICIPANTS A total of 3280 Malays aged 40+ years participated in baseline examinations of the Singapore Malay Eye Study (2004-2006). Six years later, 1901 (72.1% of eligible) baseline participants were re-examined. METHODS Cataract was assessed using lens photos, taken during eye examinations, following the Wisconsin Cataract Grading System. MAIN OUTCOMES AND MEASURES Incidence and progression of cortical, nuclear and posterior subcapsular (PSC) cataract. Poisson regression models and generalized estimating equations models (with Poisson link) were used to assess factors associated with cataract incidence and progression, respectively, adjusting for age, sex and other risk factors. RESULTS Age-adjusted 6-year incidence of cortical, nuclear and PSC cataract was 14.1%, 13.6% and 8.7%, respectively, and was strongly age-related (P for trend

Introduction: We investigated knowledge, attitudes, and practice (KAP) about COVID-19 and related preventive measures in Singaporeans aged > 60 years. Methods: This was a population-based, cross-sectional, mixed-methods study (13 May 2020–9 June 2020) of participants aged >60 years. Self-reported KAP about ten COVID-19 symptoms and six government-endorsed preventive measures were evaluated. Multivariable regression models identified sociodemographic and health-related factors associated with knowledge, attitudes and practices in our sample. Associations between knowledge/attitude scores, and practice categories were determined using logistic regression. 78 participants were interviewed qualitatively about practice of additional preventive measures and data were analysed thematically. Results: Mean awareness score of the symptoms was 7.2/10. Fever (93.0%) and diarrhoea (33.5%) were the most- and least-known symptoms, respectively. Most knew all six preventive measures (90.4%), perceived them as effective (78.7%), and practiced ‘wear a mask’ (97.2%). Indians, Malays, and those in smaller housing had poorer mean knowledge of COVID-19 symptoms scores. Older participants had poorer attitudes towards preventive measures. Compared to Chinese, Indians had lower odds of practicing 3/6 recommendations. A one-point increase in knowledge of and attitudes towards preventive measures score had higher odds of always practicing 3/6 and 2/6 measures, respectively. Qualitative interviews revealed use of other preventive measures, e.g. maintaining a healthy lifestyle. Conclusions: Elderly Singaporeans displayed high levels of KAP about COVID-19 and related preventive measures, with a positive association between levels of knowledge/attitude, and practice. However, important ethnic and socioeconomic disparities were evident, suggesting key vulnerabilities remain, requiring immediate attention.

Purpose: Artificial intelligence (AI) deep learning (DL) has been shown to have significant potential for eye disease detection and screening on retinal photographs in different clinical settings, particular in primary care. However, an automated pre-diagnosis image assessment is essential to streamline the application of the developed AI-DL algorithms. In this study, we developed and validated a DL-based pre-diagnosis assessment module for retinal photographs, targeting image quality (gradable vs. ungradable), field of view (macula-centered vs. optic-disc-centered), and laterality of the eye (right vs. left).Methods: A total of 21,348 retinal photographs from 1914 subjects from various clinical settings in Hong Kong, Singapore, and the United Kingdom were used for training, internal validation, and external testing for the DL module, developed by two DL-based algorithms (EfficientNet-B0 and MobileNet-V2).Results: For image-quality assessment, the pre-diagnosis module achieved area under the receiver operating characteristic curve (AUROC) values of 0.975, 0.999, and 0.987 in the internal validation dataset and the two external testing datasets, respectively. For field-of-view assessment, the module had an AUROC value of 1.000 in all of the datasets. For laterality-of-the-eye assessment, the module had AUROC values of 1.000, 0.999, and 0.985 in the internal validation dataset and the two external testing datasets, respectively.Conclusions: Our study showed that this three-in-one DL module for assessing image quality, field of view, and laterality of the eye of retinal photographs achieved excellent performance and generalizability across different centers and ethnicities.Translational Relevance: The proposed DL-based pre-diagnosis module realized accurate and automated assessments of image quality, field of view, and laterality of the eye of retinal photographs, which could be further integrated into AI-based models to improve operational flow for enhancing disease screening and diagnosis.

Diabetic retinopathy (DR) is a microvascular complication of diabetes mellitus, a metabolic disorder, but understanding of its pathophysiology remains incomplete. Meta-analysis of three population-based cross-sectional studies (2004–11) representing three major Asian ethnic groups (aged 40–80 years: Chinese, 592, Malays, 1052, Indians, 1320) was performed. A panel of 228 serum/plasma metabolites and 54 urinary metabolites were quantified using nuclear magnetic resonance (NMR) spectroscopy. Main outcomes were defined as any DR, moderate/above DR, and vision-threatening DR assessed from retinal photographs. The relationship between metabolites and DR outcomes was assessed using multivariate logistic regression models, and metabolites significant after Bonferroni correction were meta-analyzed. Among serum/plasma metabolites, lower levels of tyrosine and cholesterol esters to total lipids ratio in IDL and higher levels of creatinine were positively associated with all three outcomes of DR (all p &lt, 0.005). Among urinary metabolites, lower levels of citrate, ethanolamine, formate, and hypoxanthine were positively associated with all three DR outcomes (all p &lt, 0.005). Higher levels of serum/plasma 3-hydroxybutyrate and lower levels of urinary 3-hydroxyisobutyrate were associated with VTDR. Comprehensive metabolic profiling in three large Asian cohorts with DR demonstrated alterations in serum/plasma and urinary metabolites mostly related to amino acids, lipoprotein subclasses, kidney function, and glycolysis.

Background Deep learning algorithms have been built for the detection of systemic and eye diseases based on fundus photographs. The retina possesses features that can be affected by gender differences, and the extent to which these features are captured via photography differs depending on the retinal image field. Objective We aimed to compare deep learning algorithms’ performance in predicting gender based on different fields of fundus photographs (optic disc–centered, macula-centered, and peripheral fields). Methods This retrospective cross-sectional study included 172,170 fundus photographs of 9956 adults aged ≥40 years from the Singapore Epidemiology of Eye Diseases Study. Optic disc–centered, macula-centered, and peripheral field fundus images were included in this study as input data for a deep learning model for gender prediction. Performance was estimated at the individual level and image level. Receiver operating characteristic curves for binary classification were calculated. Results The deep learning algorithms predicted gender with an area under the receiver operating characteristic curve (AUC) of 0.94 at the individual level and an AUC of 0.87 at the image level. Across the three image field types, the best performance was seen when using optic disc–centered field images (younger subgroups: AUC=0.91; older subgroups: AUC=0.86), and algorithms that used peripheral field images had the lowest performance (younger subgroups: AUC=0.85; older subgroups: AUC=0.76). Across the three ethnic subgroups, algorithm performance was lowest in the Indian subgroup (AUC=0.88) compared to that in the Malay (AUC=0.91) and Chinese (AUC=0.91) subgroups when the algorithms were tested on optic disc–centered images. Algorithms’ performance in gender prediction at the image level was better in younger subgroups (aged Conclusions We confirmed that gender among the Asian population can be predicted with fundus photographs by using deep learning, and our algorithms’ performance in terms of gender prediction differed according to the field of fundus photographs, age subgroups, and ethnic groups. Our work provides a further understanding of using deep learning models for the prediction of gender-related diseases. Further validation of our findings is still needed.

Purpose The aim of this study was to determine whether cataract surgery was associated with age-related macular degeneration (AMD) development in Asian patients. Design Longitudinal cohort study. Methods Participants from the Singapore Malay and Indian Eye Studies were recruited between 2004 and 2015. A total of 6790 late-AMD-free eyes from 3475 individuals were followed for 6 years on average. Multivariable regression analysis using generalized estimating equations determined associations between cataract surgery and the incidence of any, early, and late AMD. Results The mean age (SD) of participants was 55.5 (9.1) years; 48.1% were male; 11.3% of eyes had cataract surgery recorded; incident any, early, and late AMD developed in 238 (3.6%), 222 (3.4%), and 29 (0.4%) eyes, respectively. Operated eyes had higher incidence of late AMD [1.4% vs 0.3%; adjusted risk ratio (RR): 3.47, 95% confidence interval (CI) 1.40-8.57], but not early AMD (6.0% vs 3.0%, adjusted RR: 1.12, 95% CI 0.76-1.64) or any AMD (6.9 vs 3.2%, adjusted RR: 1.23, 95% CI 0.85-1.78). Conclusions Our data are consistent with findings in population-based Caucasian studies that cataract surgery may be associated with incidence of late AMD. However, the absolute risk of late AMD development remains low and physicians should continue to balance the benefits and risks of cataract surgery in elderly patients.

To describe the rationale, design and methodology of a geographically-representative and population-based study investigating the epidemiology, impact, personal and economic burden of age-related eye diseases, declining visual and other sensory systems in Asians aged >60 years in Singapore.PIONEER (The PopulatION HEalth and Eye Disease PRofilE in Elderly Singaporeans Study) is currently a cross-sectional study targeting 3152 Chinese, Malay and Indian adults who are Singapore citizens or permanent residents aged 60 years and older living across Singapore. The study is intended to be longitudinal, with several waves of data planned to be collected in the future. The sampling frame consisted of 7000 names derived from age, gender and ethnicity-stratified random sampling of individuals >60 years. Selected individuals were invited via letters, home visits, and telephone calls for a clinical assessment at the Singapore Eye Research Institute. Individuals with limited mobility were examined in a custom-designed mobile eye clinic. Questionnaires were subsequently administered at participants' homes by trained interviewers in their preferred language. A total of 3,299 participants (from East, West, North and South Singapore) were approached from December 2017 to November 2019. Of these, 953 (28.5%) were deemed ineligible. Out of 2,346 eligible participants, 904 (38.5%) refused, and 1,442 (61.5%) attended our clinical testing protocol, giving an initial response rate of 61.5%. Of these, 1,170 (81%) were cognitively able to complete the questionnaire assessment. The mean age±SD of our participants was 73.8±8.6 years; n=798 (55.3%) were female; and 828 (57.4%) were of Chinese ethnicity. The findings from this study will allow a deeper understanding of the risk factors and impact of aging in Asian populations, particularly in relation to the visual function and other functional system.

Purpose We sought to determine the association of refractive error and its associated determinants (axial length [AL], anterior chamber depth, and corneal curvature) with the incidence and progression of diabetic retinopathy (DR). Design Population-based cohort study. Methods A total of 1562 eyes of 840 individuals with diabetes and gradable retinal photographs (mean age [SD], 57.0 [8.3] years, 48.2% female) from the Singapore Malay and Indian Eye Studies at baseline (2004–2009) and follow-up (2011–2015) examinations were included in the analyses. Refractive error was calculated as sphere plus half negative cylinder, while AL, anterior chamber depth, and corneal curvature were assessed using optical biometry. Incident DR was defined as having no baseline DR and any DR at follow-up; incident vision-threatening DR as no baseline vision-threatening DR but present at follow-up; and DR progression as an increase in severity at follow-up from at least minimal baseline DR. Eye-specific data and generalized estimating equation models were used to account for between-eye correlation to determine the relationships between the exposures and outcomes, adjusted for traditional DR risk factors. Results At follow-up, 164 of 1273 (12.9%) eyes had incident DR, 17 of 1542 (1.1%) eyes had incident vision-threatening DR, and 75 of 269 (27.9%) eyes with baseline DR experienced progression. A longer AL (per millimeter increase) (risk ratio 0.58 [95% confidence interval 0.38–0.88) was associated with a lower risk of incident DR. No other associations were found. Conclusion Our findings show that a longer AL is protective of incident DR.

BackgroundTo examine the normative profile and determinants of retinal nerve fibre layer (RNFL) symmetry in a non-glaucoma, multiethnic Asian population.MethodsChinese, Malay and Indian adults aged ≥40 years were recruited from the Singapore Epidemiology of Eye Diseases study. Participants underwent standardised systemic and ocular examinations. RNFL thickness was obtained using a spectral-domain optical coherence tomography (Cirrus HD-OCT). RNFL symmetry (in %) was calculated based on Pearson correlation coefficient between the RNFL thickness profiles of the right and left eyes. Multivariable linear regression analysis was used to investigate the associations between ocular and systemic factors with RNFL symmetry.Results4211 participants (1227 Chinese, 1245 Malays, 1739 Indians) were included. The mean RNFL symmetry was 86.7%±8.5% in Chinese, 84.7%±10.2% in Malays and 84.0%±10.7% in Indians. The fifth percentile limit of RNFL symmetry was 71.2% in Chinese, 65.0% in Malays and 62.0% in Indians. In multivariable analysis adjusting for age, gender, ethnicity, hypertension, diabetes, hyperlipidaemia, intereye absolute differences in intraocular pressure (IOP), axial length and disc area, Malays (β=−0.9; p=0.03) and Indians (β=−1.76; pConclusionsIn non-glaucoma individuals, intereye RNFL profile is less symmetric in Malays and Indians than that in Chinese. This also suggests that current commercial optical coherence tomography’s deployment of a single, universal RNFL symmetry cut-off for glaucoma detection is flawed, and ethnic-specific cut-off is warranted.

Background/aimsAlthough being a more objective tool for assessment and follow-up of angle closure, reliability studies have reported a moderate diagnostic performance for anterior segment optical coherence tomography (OCT) technologies when comparing with gonioscopy as the reference standard. We aim to determine factors associated with diagnostic disagreement in angle closure when assessed by anterior segment swept source OCT (SS-OCT, CASIA SS-1000; Tomey, Nagoya, Japan) and gonioscopy.MethodsCross-sectional study. A total of 2027 phakic subjects aged ≥50 years, with no relevant previous ophthalmic history, were consecutively recruited from a community polyclinic in Singapore. Gonioscopy and SS-OCT (128 radial scans) for the entire circumference of the angle were performed for each subject. A two-quadrant closed gonioscopic definition was used. On SS-OCT images, angle closure was defined as iridotrabecular contact (ITC) to the extent of ≥35%, ≥50% and ≥75% of the circumferential angle. Diagnostic disagreements between both methods, that is, false positives or overcalls and false negatives or undercalls were defined, respectively, as gonioscopic open/closed angles inversely assessed as closed/open by SS-OCT.ResultsTwo hundred and seventy-two (14.7%) resulted in overcall results (false positives) when ≥50% of the angle circumference was closed using SS-OCT. These eyes had significantly wider (anterior chamber width, 11.7 vs 11.6 mm, pConclusionsWe found that anterior chamber dimensions, determined by ACD and LV, were factors significantly associated with diagnostic disagreement between anterior segment SS-OCT and gonioscopy in angle closure assessment.

Background/aimsIn order to address the eye care needs of the increasing numbers of elderly Chinese globally, there is a need for comprehensive understanding on the longitudinal trends of age-related eye diseases among Chinese. We herein report the key findings from the baseline Singapore Chinese Eye Study (SCES-1), and describe the rationale and methodology of the 6-year follow-up study (SCES-2).Methods3353 Chinese adults who participated in the baseline SCES-1 (2009–2011) were invited for the 6-year follow-up SCES-2 (2015–2017). Examination procedures for SCES-2 included standardised ocular, systemic examinations and questionnaires identical to SCES-1. SCES-2 further included new examinations such as optical coherence tomography angiography, and questionnaires to evaluate health impact and economic burden of eye diseases.ResultsIn SCES-1, the age-adjusted prevalence of best-corrected low vision (VAConclusionsBuilding on SCES-1, SCES-2 will be one of the few longitudinal population-based eye studies to report incidence, progression, and risk factors of major age-related eye diseases. Findings from this cohort may offer new insights, and provide useful reference information for other Chinese populations elsewhere.

Background/aimsTo evaluate the association between systemic medications and cortical cataract prevalence in an Asian population.MethodsThe Singapore Epidemiology of Eye Diseases Study recruited 10 033 Chinese, Malay and Indian residents aged 40+ years living in Singapore. Information on medication use was collected at interview using questionnaires. The presence and severity of cortical cataract were assessed from lens photographs using the modified Wisconsin Cataract Grading System. Associations between medications and the presence of cortical cataract were assessed using logistic regression. Associations between medications and greater severity of cortical cataract (none, minimal, early and late) were assessed using ordinal logistic regression.ResultsA total of 8965 participants were included, the mean age was 57.6 (SD=9.8) years, and 4555 (50.8%) were women. After adjusting for age, gender, ethnicity, body mass index, smoking status, socioeconomic status, hypertension, hyperlipidaemia, diabetes, duration of diabetes and cardiovascular disease, ACE inhibitors (OR=1.27; 95% CI 1.05 to 1.55), fibrates (OR=1.57; 95% CI 1.05 to 2.35), alpha-glucosidase inhibitors (AGIs) (OR=1.85; 95% CI 1.13 to 3.02) and insulin (OR=1.80; 95% CI 1.11 to 2.93) were significantly associated with the presence of cortical cataract. Further adjusting for concurrent medication use did not alter these associations. Consistently, the four medications were also associated with a greater severity level of cortical cataract.ConclusionACE inhibitors, fibrates and AGIs were associated with increased prevalence of cortical cataract in this Asian population, independent of the presence of hypertension, hyperlipidaemia and diabetes, respectively. Whether they contribute to the risk of cortical cataract needs confirmation in longitudinal studies.

Background/AimsTo compensate the retinal nerve fibre layer (RNFL) thickness assessed by spectral-domain optical coherence tomography (SD-OCT) for anatomical confounders.MethodsThe Singapore Epidemiology of Eye Diseases is a population-based study, where 2698 eyes (1076 Chinese, 704 Malays and 918 Indians) with high-quality SD-OCT images from individuals without eye diseases were identified. Optic disc and macular cube scans were registered to determine the distance between fovea and optic disc centres (fovea distance) and their respective angle (fovea angle). Retinal vessels were segmented in the projection images and used to calculate the circumpapillary retinal vessel density profile. Compensated RNFL thickness was generated based on optic disc (ratio, orientation and area), fovea (distance and angle), retinal vessel density, refractive error and age. Linear regression models were used to investigate the effects of clinical factors on RNFL thickness.ResultsRetinal vessel density reduced significantly with increasing age (1487±214 µm in 40–49, 1458±208 µm in 50–59, 1429±223 µm in 60–69 and 1415±233 µm in ≥70). Compensation reduced the variability of RNFL thickness, where the effect was greatest for Chinese (10.9%; pConclusionsRNFL thickness compensated for anatomical parameters reduced the variability of measurements and may improve glaucoma detection, which needs to be confirmed in future studies.