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Objectives DRAKO (NCT02850263) is a 24-month, prospective, non-interventional, multi-centre cohort study which enroled patients diagnosed with centre-involving diabetic macular oedema (DMO). The study aims to evaluate standard of care with intravitreal aflibercept (IVT-AFL) treatment in the UK. This analysis describes the anti-vascular endothelial growth factor (anti-VEGF) treatment-naive patient cohort after 12-month follow-up. Methods Study eyes were treated with IVT-AFL as per local standard of care. The mean change in best-corrected visual acuity (BCVA) and central subfield thickness (CST) from baseline at 12 months were measured and stratified by baseline factors. The number of injections and safety data were also evaluated. Results A total of 507 patients were enroled from 35 centres. Mean (SD) baseline BCVA was 71.4 (12.0) letters and CST was 448.7 (88.7) µm, with 63.1% of patients presenting with baseline BCVA ≥ 70 letters (mean 78.1). Mean (SD) change in BCVA of 2.5 (12.2) letters and CST of −119.1 (116.4) µm was observed at month 12. A 7.3 letter gain was observed in patients with baseline BCVA Conclusion Year one results indicated that IVT-AFL was an effective treatment for DMO in standard of care UK clinical practice, maintaining or improving visual acuity in treatment-naive patients with good baseline visual acuity, despite some patients being undertreated versus the summary of product characteristics. These results also demonstrated the clinical importance and meaningful impact of diabetic retinopathy screening in the UK.

To interact successfully with diverse sensory environments, we must adapt our decision processes to account for time constraints and prior probabilities. The full set of decision-process parameters that undergo such flexible adaptation has proven to be difficult to establish using simplified models that are based on behaviour alone. Here, we utilize well-characterized human neurophysiological signatures of decision formation to construct and constrain a build-to-threshold decision model with multiple build-up (evidence accumulation and urgency) and delay components (pre- and post-decisional). The model indicates that all of these components were adapted in distinct ways and, in several instances, fundamentally differ from the conclusions of conventional diffusion modelling. The neurally informed model outcomes were corroborated by independent neural decision signal observations that were not used in the model’s construction. These findings highlight the breadth of decision-process parameters that are amenable to strategic adjustment and the value in leveraging neurophysiological measurements to quantify these adjustments. European Commission Horizon 2020 Irish Research Council Science Foundation Ireland U.S. National Science Foundation

Freezing of gait in people with Parkinson’s disease (PwP) is associated with executive dysfunction and motor preparation deficits. We have recently shown that electrophysiological markers of motor preparation, rather than decision-making, differentiate PwP with freezing of gait (FOG +) and without (FOG −) while sitting. To examine the effect of locomotion on these results, we measured behavioural and electrophysiological responses in PwP with and without FOG during a target response time task while sitting (single-task) and stepping-in-place (dual-task). Behavioural and electroencephalographic data were acquired from 18 PwP (eight FOG +) and seven young controls performing the task while sitting and stepping-in-place. FOG + had slower response times while stepping compared with sitting. However, response times were significantly faster while stepping compared with sitting for controls. Electrophysiological responses showed no difference in decision-making potentials (centroparietal positivity) between groups or conditions but there were differences in neurophysiological markers of response inhibition (N2) and motor preparation (lateralized readiness potential, LRP) in FOG + while performing a dual-task. This suggests that the addition of a second complex motor task (stepping-in-place) impacts automatic allocation of resources in FOG +, resulting in delayed response times. The impact of locomotion on the generation of the N2 and LRP potentials, particularly in freezers, indirectly implies that these functions compete with locomotion for resources. In the setting of multiple complex tasks or cognitive impairment, severe motor dysfunction may result, leading to freezing of gait.

OBJECTIVE: To explore self-inflicted retinal burns from laser pointers in children.METHODS: Literature review of laser pointer retinal injuries in childhood and online survey of UK Consultant Ophthalmologists. A cohort of local children with self-inflicted injury is described. The matter is topical. We review progress in recent legislation and policy change in the UK.RESULTS: Four of 77 case reports of laser burns in childhood analysed reported psychological or behavioural issues. Three of four children in our cohort had such issues. Delay in diagnosis occurred in two of our patients. Structural retinal damage persisted for over 12 months in all four children (seven eyes). Our survey of UK ophthalmologists found 159 cases of injury (85% male), 80% under 20 years of age. The majority of the laser pointers were purchased online. Many patients (36%) suffered moderate vision loss (6/18 to 6/60 Snellen), while 17% (at least 11 patients) suffered severe vision loss (CONCLUSION: We highlight the risk of macular damage and vision loss from handheld lasers specifically in children with behavioural, learning or mental health issues. The diagnosis may be difficult or delayed in such children. In children with uncertain macular changes, ophthalmologists should explore the history for possible instances of exposure to handheld lasers pointers. Regulatory authorities and manufacturers of handheld lasers need to be aware of the risk to children. Furthermore, there is a need to better inform parents, carers and teachers of the risk of ocular self-injury from such lasers pointers.

Purpose To define the incidence of cystoid macular edema (CME) and spectral-domain optical coherence tomography–detectable (SD-OCT) subclinical changes in central retinal thickness in patients using prostaglandin analog (PGA) eyedrops after phacoemulsification. Setting Manchester Royal Eye Hospital, Manchester, United Kingdom. Design Prospective case series. Methods A consecutive analysis of the incidence of postoperative CME after phacoemulsification by a single surgeon was performed in eyes of patients using PGA eyedrops between March 2010 and January 2014. The presence of CME was determined using SD-OCT (Cirrus) 3 weeks and 6 weeks postoperatively. Exclusion criteria included preexisting pathology known to predispose to CME and previous ophthalmic surgery. The paired Wilcoxon signed-rank test was used to compare central retinal thickness measurements at baseline and 3 weeks and 6 weeks postoperatively. Results All 48 patients (mean age 78.4 years; 60 eyes) had uneventful surgery. There were no cases of clinically significant CME. Subclinical CME detected by SD-OCT was confirmed in 2 eyes of different patients (3.3% of eyes), 1 eye 3 weeks postoperatively and another eye at 6 weeks. Subclinical CME resolved in both cases within 8 weeks. In both cases, the difference in central retinal thickness at baseline and 6 weeks postoperatively was statistically significant ( P Conclusions The incidence of subclinical CME detectable on SD-OCT after routine phacoemulsification in patients using PGA eyedrops throughout the perioperative period was 3.3%. There were no cases of clinical CME. These findings might guide clinicians in their decision to use PGAs perioperatively.

Penetrating ocular injuries from writing instruments that are thrown, especially by children, in the community can result in significant ocular morbidity. Often these cases present to the accident and emergency department. Accurate and prompt assessment is key in saving sight. We present a case of one such injury and how it was surgically managed.

We report a case of bilateral serous retinal detachment in a patient with rod-cone dystrophy caused by mutation of BEST1. This followed creatine monohydrate use as a dietary supplement. A 39-year-old male with rod-cone dystrophy and low hyperopia developed extensive bilateral exudative retinal detachment following creatine monohydrate diet supplementation. Five days after stopping creatine use, the bilateral retinal detachments resolved completely. This may indicate a causative relation of creatine supplementation to development of serous retinal detachment in a susceptible patient with pre-existing retinal dystrophy.

The neural correlates of memory formation in humans have long been investigated by exposing subjects to diverse material and comparing responses to items later remembered to those forgotten. Tasks requiring memorization of sensory sequences afford unique possibilities for linking neural memorization processes to behavior, because, rather than comparing across different items of varying content, each individual item can be examined across the successive learning states of being initially unknown, newly learned, and eventually, fully known. Sequence learning paradigms have not yet been exploited in this way, however. Here, we analyze the event-related potentials of subjects attempting to memorize sequences of visual locations over several blocks of repeated observation, with respect to pre- and post-block recall tests. Over centro-parietal regions, we observed a rapid P300 component superimposed on a broader positivity, which exhibited distinct modulations across learning states that were replicated in two separate experiments. Consistent with its well-known encoding of surprise, the P300 deflection monotonically decreased over blocks as locations became better learned and hence more expected. In contrast, the broader positivity was especially elevated at the point when a given item was newly learned, i.e., started being successfully recalled. These results implicate the Broad Positivity in endogenously-driven, intentional memory formation, whereas the P300, in processing the current stimulus to the degree that it was previously uncertain, indexes the cumulative knowledge thereby gained. The decreasing surprise/P300 effect significantly predicted learning success both across blocks and across subjects. This presents a new, neural-based means to evaluate learning capabilities independent of verbal reports, which could have considerable value in distinguishing genuine learning disabilities from difficulties to communicate the outcomes of learning, or perceptual impairments, in a range of clinical brain disorders.

PurposeTo identify the causal factors in wrong intraocular lens (IOL) events from a national data set and to compare with similar historical data (2003-2010) prior to mandatory checklist use, for the purpose of developing strategies to prevent never events.MethodsData from wrong IOL patient safety incidents (PSIs) submitted to the National Reporting and Learning System (2010-2014) were reviewed by thematic analysis and compared with the data previously collected by the group using the same methodology.ResultsOne hundred and seventy eight wrong IOL PSIs were identified. The contributory factors included: transcription errors (n=26); wrong patient biometry (n=21); wrong IOL selection (n=16); changes in planned procedure (n=16); incorrect IOL brought into theatre (n=11); left/right eye selection errors (n=9); communication errors (n=9); and positive/negative IOL power errors (n=9). In 44 PSIs, no causal factor was reported, limiting the learning value of such reports. Compared with the data from previous years, biometry errors were much reduced but IOL transcription and documentation errors were greater, particularly if further checks did not refer to the original source documentation. IOL exchange surgery was reported in 45 cases.ConclusionsThe selection and implantation of the correct IOL is a complex process which is not adequately addressed by existing checking procedures. Despite the introduction of surgical checklists, wrong IOL incidents continue to occur and are probably under-reported. Human or behavioural factors are heavily implicated in these errors and need to be addressed by novel approaches, including simulation training. There is also scope to further improve the quality and detail of incident reporting and analysis to enhance patient safety.

Over the last decades, psychophysical and electrophysiological studies in patients and animal models of Parkinson’s disease (PD), have consistently revealed a number of visual abnormalities. In particular, specific alterations of contrast sensitivity curves, electroretinogram (ERG), and visual evoked potentials (VEP), have been attributed to dopaminergic retinal depletion. However, fundamental mechanisms of cortical visual processing, such as normalization or “gain-control” computations, have not yet been examined in PD patients. Here we measured electrophysiological indices of gain control in both space (surround suppression) and time (sensory adaptation) in PD patients based on steady-state VEP (ssVEP). Compared to controls, patients exhibited a significantly higher initial ssVEP amplitude that quickly decayed over time, and greater relative suppression of ssVEP amplitude as a function of surrounding stimulus contrast. Meanwhile, EEG frequency spectra were broadly elevated in patients relative to controls. Thus, contrary to what might be expected given the reduced contrast sensitivity often reported in PD, visual neural responses are not weaker; rather, they are initially larger but undergo an exaggerated degree of spatial and temporal gain control and are embedded within a greater background noise level. We conclude that compensatory cortical mechanisms may play a role in determining dysfunctional center-surround interactions at the retinal level.

Over the last decades, psychophysical and electrophysiological studies in patients and animal models of Parkinson’s disease (PD), have consistently revealed a number of visual abnormalities. In particular, specific alterations of contrast sensitivity curves, electroretinogram (ERG), and visual-evoked potentials (VEP), have been attributed to dopaminergic retinal depletion. However, fundamental mechanisms of cortical visual processing, such as normalization or “gain control” computations, have not yet been examined in PD patients. Here, we measured electrophysiological indices of gain control in both space (surround suppression) and time (sensory adaptation) in PD patients based on steady-state VEP (ssVEP). Compared with controls, patients exhibited a significantly higher initial ssVEP amplitude that quickly decayed over time, and greater relative suppression of ssVEP amplitude as a function of surrounding stimulus contrast. Meanwhile, EEG frequency spectra were broadly elevated in patients relative to controls. Thus, contrary to what might be expected given the reduced contrast sensitivity often reported in PD, visual neural responses are not weaker; rather, they are initially larger but undergo an exaggerated degree of spatial and temporal gain control and are embedded within a greater background noise level. These differences may reflect cortical mechanisms that compensate for dysfunctional center-surround interactions at the retinal level.

Parkinson’s disease (PD) is a neurological disorder characterized by motor deficits as a result of progressive degeneration of dopaminergic neurons. Patients often report visual impairments and exhibit deficits of visual acuity, contrast sensitivity and color vision, suggesting abnormal processing of visual information. Although electrophysiological studies indicate amplitude and latency differences in patients, one of the major challenges is the lack of a conclusive, accurate, non-invasive biomarker for diagnosis and monitoring of therapeutic efficacy. In this study, we used machine learning to model and identify the most relevant signs from the EEG spectra over the span of visual stimulation. First, we used human electroencephalography (EEG) to measure visual evoked responses during steady state (ssVEP) in a visual surround suppression paradigm, in which measures of gain control and temporal aspects of the visual response are simultaneously tracked. We found an excessive response gain profile of the contrast response function, and an abnormally greater background noise level in PD patients compared to healthy controls. Second, performance of three learning models was tested: logistic regression, decision tree and extra tree. Together, these provide powerful insights about the most relevant features that allow classifying patients from controls. These models contribute with new hints on the interpretation of functional abnormalities in PD based on spectral EEG during visual stimulation. Machine learning provides a promising tool for accurate and robust prediction in PD diagnosis, based on EEG signatures during visual information processing.

A middle-aged man presented to emergency services with central vision loss in the setting of flu-like illness with fever. A striking subfoveal abscess was observed in the right fundus. Focal acute chorioretinal inflammation was noted in the asymptomatic fellow eye. Staphylococcus aureus septicaemia was subsequently diagnosed. He presented with undiagnosed HIV infection and latent syphilis. Serial high-definition multimodal retinal imaging showcased resolution of the dome-shaped subretinal abscess following treatment with intravenous flucloxacillin. A chorioretinal scar swiftly replaced the subfoveal abscess. Peripheral right vision and full left vision was retained. Vision loss due to endogenous endophthalmitis in systemic sepsis is an emergency requiring prompt multidisciplinary care. Sight and life are at risk—thus this is not a diagnosis to miss! Early recognition is paramount to health and in retaining vision. We briefly review relevant literature and portray how multimodal imaging guided response to treatment of acute subretinal abscess.

Gyrate atrophy is a rare autosomal recessive disorder caused by a mutation in the ornithine-δ-amino transferase gene. We present an interesting case of a 33-year-old woman who presented with increasing myopia, nyctalopia and failing vision. Examination revealed posterior subscapsular cataracts, narrowed peripheral visual fields and scalloped atrophic peripheral chorioretinal lesions. Blood investigations showed a raised plasma ornithine level at 917 μmol/L (normal range: 32-88 μmol/L) confirming the diagnosis of gyrate atrophy. The patient, despite not tolerating dietary treatment, had retained central vision over a follow-up period of 18 years. The electroretinogram, which normally diminishes with disease progression, was still nearly normal when last tested at 16 years follow-up. Genetic testing did not reveal any novel mutation that could account for this variation.

In situations in which impending sensory events demand fast action choices, we must be ready to prioritize higher-value courses of action to avoid missed opportunities. When such a situation first presents itself, stimulus–action contingencies and their relative value must be encoded to establish a value-biased state of preparation for an impending sensorimotor decision. Here, we sought to identify neurophysiological signatures of such processes in the human brain (both female and male). We devised a task requiring fast action choices based on the discrimination of a simple visual cue in which the differently valued sensory alternatives were presented 750–800 ms before as peripheral “targets” that specified the stimulus–action mapping for the upcoming decision. In response to the targets, we identified a discrete, transient, spatially selective signal in the event-related potential (ERP), which scaled with relative value and strongly predicted the degree of behavioral bias in the upcoming decision both across and within subjects. This signal is not compatible with any hitherto known ERP signature of spatial selection and also bears novel distinctions with respect to characterizations of value-sensitive, spatially selective activity found in sensorimotor areas of nonhuman primates. Specifically, a series of follow-up experiments revealed that the signal was reliably invoked regardless of response laterality, response modality, sensory feature, and reward valence. It was absent, however, when the response deadline was relaxed and the strategic need for biasing removed. Therefore, more than passively representing value or salience, the signal appears to play a versatile and active role in adaptive sensorimotor prioritization.SIGNIFICANCE STATEMENTIn many situations such as fast-moving sports, we must be ready to act fast in response to sensory events and, in our preparation, prioritize courses of action that lead to greater rewards. Although behavioral effects of value biases in sensorimotor decision making have been widely studied, little is known about the neural processes that set these biases in place beforehand. Here, we report the discovery of a transient, spatially selective neural signal in humans that encodes the relative value of competing decision alternatives and strongly predicts behavioral value biases in decisions made ∼500 ms later. Follow-up manipulations of value differential, reward valence, response modality, sensory features, and time constraints establish that the signal reflects an active, feature- and effector-general preparatory mechanism for value-based prioritization.

In natural behavior, animals have access to multiple sources of information, but only a few of these sources are relevant for learning and actions. Beyond choosing an appropriate action, making good decisions entails the ability to choose the relevant information, but fundamental questions remain about the brain's information sampling policies. Recent studies described the neural correlates of seeking information about a reward, but it remains unknown whether, and how, neurons encode choices of instrumental information, in contexts in which the information guides subsequent actions. Here we show that parietal cortical neurons involved in oculomotor decisions encode, before an information sampling saccade, the reduction in uncertainty that the saccade is expected to bring for a subsequent action. These responses were distinct from the neurons' visual and saccadic modulations and from signals of expected reward or reward prediction errors. Therefore, even in an instrumental context when information and reward gains are closely correlated, individual cells encode decision variables that are based on informational factors and can guide the active sampling of action-relevant cues.

Primate neocortex contains over 30 visual areas. Recent techniques such as functional magnetic resonance imaging (fMRI) have successfully identified many of these areas in the human brain, but have been of limited value for revealing the temporal dynamics between visual areas. The electroencephalogram (EEG) provides information with high temporal precision, but has had limited success separating out the signals from individual neighboring cortical areas. Consequently, controversies exist over the temporal dynamics across cortical areas. In order to address this problem we developed a new method to identify the sources of the EEG. An individual’s unique cortical pattern of sulci and gyri along with a visual area’s functional retinotopic layout provides a folding fingerprint that predicts specific scalp topographies for stimuli presented in different parts of the visual field. Using this folding fingerprint with a 96 or 192 location stimulus severely constrains the solution space making it relatively easy to extract the temporal response of multiple visual areas to multiple stimulus locations. The large number of stimuli also provides a means to validate the waveforms by comparing across stimulus sets, an important feature not present in most EEG source identification procedures. Using this method our data reveals that both V1 and V2 waveforms have similar onset latencies, and their temporal dynamics provide new information regarding the response latencies of these areas in humans. Our method enables the previously unattainable separation of EEG responses from neighboring brain areas. While we applied the method to the first two cortical visual areas, V1 and V2, this method is also applicable to somatosensory areas that have defined mappings. This method provides a means to study the rapid information flow in the human brain to reveal top-down and bottom-up cognitive processes.

To analyse the incidence and baseline clinical characteristics of patients with neovascular age-related macular degeneration (nAMD) treated with intravitreal anti-vascular endothelial growth factor (VEGF) injections in a defined UK region.A standardised dataset was collected prospectively using an electronic medical record (EMR) system from 1 January 2008 to 21 June 2012 for all patients living in Gloucestershire who received intravitreal anti-VEGF injections for nAMD.Over the study period, 1207 eyes from 1033 patients began intravitreal anti-VEGF injections for nAMD. The annual incidence in the years after National Institute for Health and Care Excellence (NICE) technology appraisal 155 implementation was stable at 120 (95% CI 110 to 138) eyes or 100 (89 to 115) people per 100 000 population. The most common indication was occult choroidal neovascularisation (51%). Median baseline visual acuity (VA) was significantly higher for second treated than first treated eyes (66 and 56 letters, respectively; p0.0001). Median baseline VA of fellow eyes increased from 47 (2008) to 67 letters (2012; p0.005). The proportion of patients with baseline VA in the better eye ≥70 letters increased from 27.6% (2008) to 51.4% (2012; p0.0001), while the proportion eligible at baseline for full or partial certificate of visual impairment decreased from 13.8% (2008) to 7.1% (2012; p0.05).The incidence of patients undergoing anti-VEGF therapy for nAMD increased substantially following NICE approval of ranibizumab (August 2008), and has been stable since 2009. This equates to an annual UK incidence of 26 850 (21 320 to 32 440) eyes, similar to NICE estimates. Patients eligible for blindness certification before treatment decreased by half from 2008-2012. Prospective data collection using an EMR system is invaluable for efficient monitoring of real-world clinical care.

The World Health Organisation (WHO) identified patient safety in surgery as an important public health matter and advised the adoption of a universal peri-operative surgical checklist. An adapted version of the WHO checklist has been mandatory in the National Health Service since 2010. Wrong intraocular lens (IOL) implantation is a particular safety concern in ophthalmology. The Royal College of Ophthalmologists launched a bespoke checklist for cataract surgery in 2010 to reduce the likelihood of preventable errors. We sought to ascertain the use of checklists in cataract surgery in 2012. A survey of members of the Royal College of Ophthalmologists seeking views on the use of checklists in cataract surgery. Four hundred and sixty-nine completed responses were received (18% response rate). Respondents worked in England (75%), Scotland (11%), Wales (5%), Northern Ireland (2%), the Republic of Ireland (1%), and overseas (6%). Ninety-four per cent of respondents support the use of a checklist for cataract surgery and 85% say that they always use a checklist before cataract surgery. Sixty-seven per cent of cataract surgeons stated they undertake a pre-operative team brief. Thirty-six per cent use a cataract surgery checklist developed locally, 18% use the college’s bespoke cataract surgery checklist, 39% use a generic surgical checklist, and 4% reported that they do not use a checklist. Ninety-three per cent of cataract surgeons responding to the questionnaire report using a surgical checklist and 67% use a team brief. However, only 54% use a checklist, which addresses the selection of the correct intraocular implant. We recommend wider adoption of checklists, which address risks relevant to cataract surgery, in particular the possibility of selection of an incorrect IOL.

We present a dataset combining electrophysiology and eye tracking intended as a resource for the investigation of information processing in the developing brain. The dataset includes high-density task-based and task-free EEG, eye tracking, and cognitive and behavioral data collected from 126 individuals (ages: 6–44). The task battery spans both the simple/complex and passive/active dimensions to cover a range of approaches prevalent in modern cognitive neuroscience. The active task paradigms facilitate principled deconstruction of core components of task performance in the developing brain, whereas the passive paradigms permit the examination of intrinsic functional network activity during varying amounts of external stimulation. Alongside these neurophysiological data, we include an abbreviated cognitive test battery and questionnaire-based measures of psychiatric functioning. We hope that this dataset will lead to the development of novel assays of neural processes fundamental to information processing, which can be used to index healthy brain development as well as detect pathologic processes.

A man aged 59 years old presented with sudden, painless, monocular visual loss due to central retinal artery occlusion. Central vision was retained and peripheral vision lost due to retained cilioretinal perfusion. Increased inner retinal thickening and reflectivity followed by subsequent reduction was documented by sequential imaging. This is the first report of such events monitored with spectral-domain optical coherence tomography where central visual acuity was maintained.

Brain networks subserving alertness in humans interact with those for spatial attention orienting. We employed blue-enriched light to directly manipulate alertness in healthy volunteers. We show for the first time that prior exposure to higher, relative to lower, intensities of blue-enriched light speeds response times to left, but not right, hemifield visual stimuli, via an asymmetric effect on right-hemisphere parieto-occipital α-power. Our data give rise to the tantalising possibility of light-based interventions for right hemisphere disorders of spatial attention.

Attentional engagement is a major determinant of how effectively we gather information through our senses. Alongside the sheer growth in the amount and variety of information content that we are presented with through modern media, there is increased variability in the degree to which we “absorb” that information. Traditional research on attention has illuminated the basic principles of sensory selection to isolated features or locations, but it provides little insight into the neural underpinnings of our attentional engagement with modern naturalistic content. Here, we show in human subjects that the reliability of an individual's neural responses with respect to a larger group provides a highly robust index of the level of attentional engagement with a naturalistic narrative stimulus. Specifically, fast electroencephalographic evoked responses were more strongly correlated across subjects when naturally attending to auditory or audiovisual narratives than when attention was directed inward to a mental arithmetic task during stimulus presentation. This effect was strongest for audiovisual stimuli with a cohesive narrative and greatly reduced for speech stimuli lacking meaning. For compelling audiovisual narratives, the effect is remarkably strong, allowing perfect discrimination between attentional state across individuals. Control experiments rule out possible confounds related to altered eye movement trajectories or order of presentation. We conclude that reliability of evoked activity reproduced across subjects viewing the same movie is highly sensitive to the attentional state of the viewer and listener, which is aided by a cohesive narrative.SIGNIFICANCE STATEMENTModern technology has brought about a monumental surge in the availability of information. There is a pressing need for ways to measure and characterize attentional engagement and understand the causes of its waxing and waning in natural settings. The present study demonstrates that the degree of an individual's attentional engagement with naturalistic narrative stimuli is strongly predicted by the degree of similarity of his/her neural responses to a wider group. The effect is so strong that it enables perfect classification of attentional state across individuals for some narrative stimuli. As modern information content continues to diversify, such direct neural metrics will become increasingly important to manage and evaluate its effects on both the healthy and disordered human brain.

Aims Vitreoretinal (VR) surgery is complex. Most clinical conditions that VR surgeons manage have a high risk for blindness or severe visual impairment. Reporting of patient safety incidents (PSI) in VR surgery was introduced at the Moorfields Eye Hospital (MEH) in the 1990s. We examine the role of PSI reporting in making VR surgery safer at our institution. Methods Qualitative review of PSIs from 1997 to 2009 at MEH, London, UK. Results Over the 13-year study period, 38 789 VR procedures were undertaken and 579 VR PSIs occurring in theatre or inpatient were reported. Mean rate of PSI reporting was 1.49% (range 0.12–3.35). In comparison, the mean rate of PSI reporting over the same period across all National Health Service ophthalmology in England was 0.59% (range 0.36–0.49). Overall, 0.9% of VR PSI resulted in ‘Severe’ harm, 11.6% in ‘Moderate’ harm and 87.5% in ‘No’ or ‘Low’ harm. 15 (2.6%) of PSIs directly resulted in a change in clinical practice, 13 of which occurred in the first half of the study period. 12 (3.6%) critical incidents were violations of pre-existing protocols and guidelines, eight of which occurred in the second half of the study period. 61 (10.9%) of PSIs fell into nine main error subtypes that contributed to a change in practice. The most common were ocular hypotony (2.9%), medical device failure (2.8%) and delay in VR surgery (1.2%). Conclusions VR PSI reporting resulted in a change in clinical practice. Longitudinal analysis suggests an accompanying increase in patient safety.

Vascular endothelial growth factor (VEGF) inhibitor medications such as ranibizumab, pegaptanib and bevacizumab are in use for the treatment of neovascular age-related macular degeneration (AMD) and other retinal conditions, although only ranibizumab and pegaptanib are approved for these conditions. In contrast, bevacizumab was developed for the intravenous systemic treatment of colorectal cancer and is not formulated for intravitreal use, but is commonly used off-label in ophthalmology. European Union legislation permits the use of drugs outside the terms of their licence ('off-label') only under certain circumstances, such as during clinical trials, compassionate/named patient use in the absence of a licensed alternative, emergency scenarios (e.g., pandemics) or at the discretion of a treating physician. In such cases, patients should be fully informed regarding their treatment and any potential risks involved. Off-label drug use can be an important tool to provide patients with treatment in cases of unmet medical need. However, the use of an unlicensed medicinal product, when a suitable licensed alternative is available, puts prescribing physicians at risk of liability if safety issues arise. Emerging clinical evidence suggests safety differences exist between ranibizumab and bevacizumab.

Simon P Kelly1, Ian Wallwork2, David Haider1, Kashif Qureshi11Ophthalmology Department, Royal Bolton Hospital National Health Service Foundation Trust, Bolton, 2Wallwork Opticians, Salford, UKPurpose: To describe a quality improvement for referral of National Health Service patients with macular disorders from a community optometry setting in an urban area.Methods: Service evaluation of teleophthalmology consultation based on spectral domain optical coherence tomography images acquired by the community optometrist and transmitted to hospital eye services.Results: Fifty patients with suspected macular conditions were managed via telemedicine consultation over 1 year. Responses were provided by hospital eye service-based ophthalmologists to the community optometrist or patient within the next day in 48 cases (96%) and in 34 (68%) patients on the same day. In the consensus opinion of the optometrist and ophthalmologist, 33 (66%) patients required further “face-to-face” medical examination and were triaged on clinical urgency. Seventeen cases (34%) were managed in the community and are a potential cost improvement. Specialty trainees were supervised in telemedicine consultations.Conclusion: Innovation and quality improvement were demonstrated in both optometry to ophthalmology referrals and in primary optometric care by use of telemedicine with spectral domain optical coherence tomography images. E-referral of spectral domain optical coherence tomography images assists triage of macular patients and swifter care of urgent cases. Teleophthalmology is also, in the authors’ opinion, a tool to improve interdisciplinary professional working with community optometrists. Implications for progress are discussed.Keywords: telemedicine, teleophthalmology, innovation, community referral, optical coherence tomography, service evaluation

Simon P Kelly, Graham MB ReevesThe Royal Bolton Hospital, Bolton, UKPurpose: To consider the potential for ocular injury from writing implements by presenting four such cases, and to consider the incidence of such eye injuries from analysis of a national trauma database.Methods: The Home and Leisure Accident Surveillance System was searched for records of eye injuries from writing instruments to provide UK estimates of such injuries. Four patients with ocular penetrating injury from pens or pencils (especially when caused by children), and examined by the authors, are described which illustrate mechanisms of injury.Results: It is estimated that around 748 ocular pen injuries and 892 ocular pencil injuries of undetermined severity occurred annually in the UK during the database surveillance period 2000–2002. No eye injuries from swords, including toy swords and fencing foils, were reported.Conclusion: Ocular perforation sometimes occur from writing instruments that are thrown in the community, especially by children. Implications for policy and prevention are discussed. Non-specialists should have a low threshold for referring patients with eye injuries if suspicious of ocular penetration, even where caused by everyday objects, such as writing instruments.Keywords: eye injury, eye, children, mechanism, writing instruments, prevention

A retired woman with left ophthalmic shingles of over 2 years' duration attended with bilateral vision loss and systemic upset. Acute retinal necrosis with detachment was detected on right fundus examination. Cataract in left eye precluded funduscopy. Ocular ultrasonography revealed fibrotic retinal detachment in the left eye. MRI brain and orbits also showed signals of retinal detachment. No abnormal MRI signal within the optic nerve or brain was found. Varicella zoster virus was detected in ocular aqueous and blood samples. High-dose intravenous acyclovir was administered. HIV test was positive with a very low CD4 count. Antiretroviral medications were prescribed. There was no recovery of vision. She was certified as blind, and social services were involved in seeking to provide alterations to her home in view of her severe disability. This case highlights the importance of suspecting HIV in patients with severe or chronic ophthalmic shingles. Images and implications for clinical practice are presented.

Purpose To evaluate the epidemiologic evidence for a causal association between tobacco smoking and primary open angle glaucoma (POAG). Methods Systematic review, including quality assessment, of published analytical epidemiologic studies and evaluation of the evidence using established causality criteria (strength, consistency, temporality, dose response, reversibility, and biologic plausibility). Results Eleven papers describing 9 case-control studies, 1 prospective cohort study, and a paper describing a pooled analysis based on 2 prospective cohort studies were included in the review. The methodologic quality of most included studies was poor. The strongest studies methodologically were the cohort studies on which the pooled analysis was based. Neither the prospective cohort study (rate ratio not reported) nor the pooled analysis of 2 prospective cohort studies (adjusted rate ratio 0.9) found an association between smoking and POAG. There was a significant positive association between smoking and POAG in only 2 of the case-control studies (adjusted odds ratio 2.9 and 10.8). There was no evidence of a dose-response relationship with smoking or of reversibility of effect in the studies where this was assessed. Conclusions This systematic review provided little evidence for a causal association between smoking and development of POAG. Given the limited evidence from high quality studies, and the possibility that flaws in many of the studies reviewed biased the results toward the null, further high quality research to confirm our conclusions is needed. However, it remains important to warn ophthalmic patients of the dangers of smoking and provide cessation support owing to the clear evidence of links between smoking and other ocular and systemic diseases.

Objective Community pharmacists have a central role in provision of smoking-cessation support. Evidence is growing that tobacco smoking is associated with development and progression of several potentially blinding eye diseases. As part of an ongoing programme of raising awareness of this link, we investigated whether community pharmacists are aware of this association and incorporate relevant advice into their smoking-cessation guidance. Setting Two-thousand and eighty community pharmacists in north west England, UK. Method A postal self-completion questionnaire asked pharmacists about their current practice with regard to smoking habits of their clients. Data were extracted and entered onto a database for statistical analyses. Key findings The response rate was 50.5%; 685 (65.2%) pharmacists asked clients about smoking habits; the most common situation was when clients complained of respiratory symptoms. Of these pharmacists, 52.7% always/usually recommended that smokers should stop and 37.2% always/usually assessed motivation to succeed. Help provided by pharmacists included brief advice on smoking cessation, leaflets, more structured support, referral to smoking-cessation services, and nicotine replacement therapies. The most common reason why pharmacists did not ask about smoking was lack of time (83.1%); 52.0% were aware of the causal association of smoking with eye disease, and 19.8% of those who asked about smoking habits mentioned this association when discussing smoking cessation. Conclusion Our study shows that community pharmacists are actively involved in smoking cessation. Many pharmacists are aware of the causal association between smoking and eye disease, but few are actively counselling patients about the eye heath risks of smoking. Community pharmacists could include this information in their advice to clients who smoke, as an additional means to promote smoking cessation.

Purpose: Intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents including ranibizumab and aflibercept are used to treat patients with ocular disorders such as neovascular age-related macular degeneration (nAMD); however, the injections are associated with rare instances of severe ocular inflammation. This study compared severe ocular inflammation rates in patients treated with ranibizumab versus aflibercept. Methods: United States physician-level claims data covering an 18-month period for each therapy were analyzed. The primary analysis compared severe ocular inflammation event rates per 1000 injections. Sensitivity and subgroup analyses evaluated the impact of factors including intraocular surgery, intravitreal antibiotic administration, and previous intravitreal injections. Results: The analysis included 432,794 injection claims (ranibizumab n = 253,647, aflibercept n = 179,147); significantly, more unique severe ocular inflammation events occurred in patients receiving aflibercept than ranibizumab (1.06/1000 injections, 95% confidence interval [CI], 0.91–1.21, vs. 0.64/1000 injections, 95% CI 0.54–0.74; p < 0.0001). Comparable results were observed for analyses of patients who had undergone glaucoma or cataract surgeries, had antibiotic-associated endophthalmitis, had non-antibiotic-associated endophthalmitis, and were non-treatment-naive. In contrast, no significant differences in severe ocular inflammation claims were recorded in treatment-naive patients who had no record of anti-VEGF treatment in the 6 months preceding the index claim. No significant change occurred in the rate of severe ocular inflammation claims over time following ranibizumab treatment. Conclusions: Severe ocular inflammation was more frequent following intravitreal injection with aflibercept than with ranibizumab during routine clinical use in patients with nAMD. This highlights the importance of real-world, post-approval, observational monitoring of novel medicines, and may aid clinical decision-making, including choice of anti-VEGF agent.

In natural visual environments, we use attention to select between relevant and irrelevant stimuli that are presented simultaneously. Our attention to objects in our visual field is largely controlled endogenously, but is also affected exogenously through the influence of novel stimuli and events. The study of endogenous and exogenous attention as separate mechanisms has been possible in behavioral and functional imaging studies, where multiple stimuli can be presented continuously and simultaneously. It has also been possible in electroencephalogram studies using the steady-state visual-evoked potential (SSVEP); however, it has not been possible in conventional event-related potential (ERP) studies, which are hampered by the need to present suddenly onsetting stimuli in isolation. This is unfortunate as the ERP technique allows for the analysis of human physiology with much greater temporal resolution than functional magnetic resonance imaging or the SSVEP. While ERP studies of endogenous attention have been widely reported, these experiments have a serious limitation in that the suddenly onsetting stimuli, used to elicit the ERP, inevitably have an exogenous, attention-grabbing effect. Recently we have shown that it is possible to derive separate event-related responses to concurrent, continuously presented stimuli using the VESPA (visual-evoked spread spectrum analysis) technique. In this study we employed an experimental paradigm based on this method, in which two pairs of diagonally opposite, non-contiguous disc-segment stimuli were presented, one pair to be ignored and the other to be attended. VESPA responses derived for each pair showed a strong modulation at 90–100 ms (during the visual P1 component), demonstrating the utility of the method for isolating endogenous visuospatial attention effects.

Aim: To assess community optometrists’ attitudes and current behaviour regarding provision of smoking cessation advice in their practice. Methods: A self-completion postal questionnaire was sent to community optometrists in north-west England identified from the General Optical Council's practice lists. Results: Of 709 optometrists identified, 71.8% (509/709) returned the completed questionnaire. Few community optometrists routinely asked about smoking habits: only 6.2% (95% CI: 4.1–8.3) (n = 31) at new patient consultations, and 2.2% (95% CI: 0.9–3.5) (n = 11) at follow-up visits. Reasons for optometrists not routinely providing smoking cessation advice included: not their role (35.4%, n = 180), lack of time (22.0%, n = 112) and forgetting to ask (21.4%, n = 109). Overall 67.6% (95% CI: 63.5–71.7) (n = 344) of community optometrists wanted to improve their knowledge of smoking and visual impairment with 56.2% (95% CI: 51.9–60.5) (n = 286) requesting further training. Conclusion: Despite low levels of current involvement, many optometrists were keen to receive training on smoking cessation topics. We suggest that there are untapped opportunities to develop brief interventions to promote smoking cessation services in community optometry settings.

Several risk factors for the development of cataract have been identified. This review evaluates epidemiologic literature that has examined tobacco smoking as a risk factor for cataract formation using established causality criteria. Twenty-seven studies were included in this review. Evidence suggests that smoking has a 3-fold increase on the risk for incident nuclear cataract development. There was also evidence of dose response, temporal relationship, and reversibility of effect. There was limited evidence of an association between smoking and posterior subcapsular cataract, but little or no association with cortical cataract. Thus, the literature review indicated a strong association between smoking and the development of cataract, particularly nuclear cataract. The association fulfills the established criteria for causality. The association between smoking and other types of cataract is less distinct and requires further evaluation.

Smoking is associated with several serious eye diseases. Awareness of smoking and blindness, and its potential to act, as a stimulus to assist stopping smoking has not been investigated. A cross-sectional survey using a structured interview of adult patients attending district general hospital ophthalmology, general surgery, and orthopaedic clinics. The interview investigated the awareness and fear of blindness for three established smoking-related diseases, and a distractor condition (deafness), and the likelihood that smokers would quit on developing early signs of each condition. Response was 89.1% (358/402). In all, 183 (51.1%) of responders were male and 175 (48.9%) female. Only 9.5% of patients believed that smoking was definitely or probably a cause of blindness, compared with 92.2% for lung cancer, 87.6% for heart disease, and 70.6% for stroke. Patients ranked their fear of each of the five conditions, scoring five for the most feared and one for the least feared. Patients were significantly (P

PURPOSE: The recent focus on healthcare errors and safety suggest that practitioners and policy makers might appraise their cataract surgical care from a patient safety perspective. This paper reviews patient safety issues relevant to cataract care. Causation and consequences of incidents in cataract surgery, with implications for policy, are discussed. METHODS: Models of accident causation from other domains were drawn on and empirically applied to cataract care. Consultation was undertaken with experts in cataract surgery, patient safety, and in risk management. Feedback on patient safety was included from presentations made to staff and patients and from personal insights. RESULTS: Ophthalmology teams should embrace steps to improve patient safety. The role of incident reporting is advanced, including the provision of a prompt menu of cataract patient safety incidents as suggested by the Royal College of Ophthalmologists. CONCLUSIONS: Strict attention to detail, risk assessment, and careful consideration of the patient pathway is needed to enhance cataract care. Clinical errors, near misses and complications happen, and may provide an opportunity for learning to reduce the risk of similar events in the future. Investment in staffing and training, appropriate equipment, and development of a safety culture with patient involvement are key elements of safe cataract surgical care. Patients and the public expect that safe cataract care should be commissioned for them. Critical patient safety incidents, including incidents that have led to permanent harm, require careful analysis of underlying systems and/or root causes.

The P300 component of the human event-related potential has been the subject of intensive experimental investigation across a five-decade period, owing to its apparent relevance to a wide range of cognitive functions and its sensitivity to numerous brain disorders, yet its exact contribution to cognition remains unresolved. Here, we carry out key analyses of the P300 elicited by transient auditory and visual targets to examine its potential role as a ‘decision variable’ signal that accumulates evidence to a decision bound. Consistent with the latter, we find that the P300 reaches a stereotyped amplitude immediately prior to response execution and that its rate of rise scales with target detection difficulty and accounts for trial-to-trial variance in RT. Computational simulations of an accumulation-to-bound decision process faithfully captured P300 dynamics when its parameters were set by model fits to the RT distributions. Thus, where the dominant explanatory accounts have conceived of the P300 as a unitary neural event, our data reveal it to be a dynamically evolving neural signature of decision formation. These findings place the P300 at the heart of a mechanistically principled framework for understanding decision-making in both the typical and atypical human brain.

Surround suppression is a well-known example of contextual interaction in visual cortical neurophysiology, whereby the neural response to a stimulus presented within a neuron's classical receptive field is suppressed by surrounding stimuli. Human psychophysical reports present an obvious analog to the effects seen at the single-neuron level: stimuli are perceived as lower-contrast when embedded in a surround. Here we report on a visual paradigm that provides relatively direct, straightforward indices of surround suppression in human electrophysiology, enabling us to reproduce several well-known neurophysiological and psychophysical effects, and to conduct new analyses of temporal trends and retinal location effects. Steady-state visual evoked potentials (SSVEP) elicited by flickering “foreground” stimuli were measured in the context of various static surround patterns. Early visual cortex geometry and retinotopic organization were exploited to enhance SSVEP amplitude. The foreground response was strongly suppressed as a monotonic function of surround contrast. Furthermore, suppression was stronger for surrounds of matching orientation than orthogonally-oriented ones, and stronger at peripheral than foveal locations. These patterns were reproduced in psychophysical reports of perceived contrast, and peripheral electrophysiological suppression effects correlated with psychophysical effects across subjects. Temporal analysis of SSVEP amplitude revealed short-term contrast adaptation effects that caused the foreground signal to either fall or grow over time, depending on the relative contrast of the surround, consistent with stronger adaptation of the suppressive drive. This electrophysiology paradigm has clinical potential in indexing not just visual deficits but possibly gain control deficits expressed more widely in the disordered brain.

Monica M Michelotti,1 Salwa Abugreen,2 Simon P Kelly,1 Jiten Morarji,1 Debra Myerscough,2 Tina Boddie,2 Ann Haughton,1 Natalie Nixon,2 Brenda Mason,1 Evangelos Sioras11Ophthalmology Department, Royal Bolton Hospital NHS Foundation Trust, Bolton, UK; 2Ophthalmology Department, East Lancashire NHS Trust, Blackburn, UKBackground: The dramatic increase in need for anti-vascular endothelial growth factor (anti-VEGF) intravitreal therapy in the treatment of retinal disease and the absence of an equivalent increase in ophthalmologists to undertake such intravitreal injections created a patient-safety risk. Timing of intravitreal therapy (IVT) is critical to prevent vision loss and local clinics lacked capacity to treat patients appropriately. We aimed to improve capacity for IVT by nurse injections.Materials and methods: A multidisciplinary prospective service-improvement process was undertaken at two adjacent general hospitals in the northwest of England. IVT injections by nurses were a principal component of solution development. After we had obtained appropriate institutional approval, experienced ophthalmic nurses were trained, supervised, and assessed to undertake IVT. Ophthalmologists directly supervised the first 200 injections, and a retina specialist was always on site.Results: Nurses undertook 3,355 intravitreal injections between June 2012 and November 2013, with minor adverse events (0.3% subconjunctival hemorrhage and corneal abrasion). There were no patient complaints at either hospital.Conclusion: Experienced ophthalmic nurses quickly learned how to perform such injections safely. IVT by nurses was well accepted by patients and staff. Hospital A trained three nurses sequentially for improved flexibility in scheduling. Novel use of appropriately trained nonmedical staff can improve efficiency and access in an overburdened service with time-sensitive disease. Retinal assessment was undertaken by ophthalmologists only. Improved access to IVT is important, as treatment with anti-VEGF therapy reduces blindness at population levels.Keywords: ophthalmology, retina, age-related macular degeneration, nurse, transformation, extended roles

Objective To assess whether central corneal thickness (CCT) is a confounding factor in the classification of patients attending for glaucoma assessment in a district general hospital. Design Cross-sectional study by a single observer. Participants Patients attending a general ophthalmic clinic: 235 clinically normal eyes, 52 eyes with normal-tension glaucoma (NTG), 335 eyes with primary open-angle glaucoma (POAG), 12 eyes with pseudoexfoliative glaucoma (PXE), 42 eyes with chronic angle closure glaucoma (CACG), and 232 glaucoma suspect (GS) eyes. Intervention Central corneal thickness was measured using ultrasonic pachymetry. Main outcome measure Correlation of CCT and diagnosis. Results Mean CCT was 553.9 μm (95% confidence intervals [CI] for the mean, 549.0–558.8 μm) in the clinically normal eyes, 550.1 μm (95% CI, 546.6–553.7 μm) in the POAG eyes, 514.0 μm (95% CI, 504.8–523.3 μm) in the NTG eyes, 530.7 μm (95% CI, 511.2–550.1 μm) in the PXE eyes, 559.9 μm (95% CI, 546.8–573.0 μm) in the CACG eyes, and 579.5 μm (95% CI, 574.8–584.1 μm) in the GS eyes. The differences of mean CCT between the groups were highly significant ( P Conclusions The CCT measurement is desirable in patients attending for glaucoma assessment in a district general hospital to avoid misclassification resulting from the relationship between CCT and tonometric pressure. Central corneal thickness alone is not an accurate predictor for the clinical diagnosis in this group of eyes. However, many eyes diagnosed as having NTG have thin corneas, which would tend to lower the tonometrically recorded intraocular pressure (IOP), so the finding of a less-than-normal thickness cornea introduces some doubt as to the diagnosis of NTG. For the GS eyes, most eyes had thick corneas, which would tend to increase the tonometrically recorded IOP. Thus, GS eyes with modest elevation of IOP and a thick cornea may be at low risk of progressing to POAG. Thus, many patients with "high IOPs" and a thick CCT do not necessarily have high IOPs and may not need to be followed as GS eyes.

Two patients with ischaemic central retinal vein occlusion were treated with intracameral bevacizumab in order to affect the outcome of their disease. In addition, both patients underwent episodes of cycloablative and pan-retinal laser treatment. The patients were followed for more than 6 months and achieved some stability with a combination of these modalities.

Cigarette smoking often starts in teenage years. It is not known whether teenagers are aware of the association of smoking with eye disease and blindness.To explore the knowledge of the link between smoking, and eye diseases and blindness, and the likely impact of this knowledge among teenagers in UK.A cross-sectional survey, using a structured interview of teenagers attending four organised social events, was conducted. Awareness and fear of blindness, and of three smoking-related diseases (lung cancer, heart disease and stroke) and a distractor condition (deafness) was investigated. The likelihood of smokers quitting on developing early signs of each condition was determined.A 92% "opt in" response rate was achieved. Out of 260 teenagers (16-18 years), 15%, 27% and 81% believed that smoking caused stroke, heart disease and lung cancer, respectively. Only 5% believed smoking caused blindness. Subjects ranked their fear of each of the five conditions, scoring five for the most feared and one for the least feared. Subjects were significantly (p0.01) more fearful (mean scores in brackets) of blindness (4.2) than of lung cancer (3.4), heart disease (2.3) and deafness (1.2). More teenagers (p0.01) said they would stop smoking on developing early signs of blindness compared with early signs of lung or heart disease.Awareness of the risk of blindness from smoking is low among teenagers, but fear of blindness may be more likely to motivate teenagers to stop smoking than fear of lung or heart disease. Teenagers should be made more aware of the ocular risks of cigarette smoking as a novel public health measure.

Correction to: Eye (2015) 29, 721–731; doi:10.1038/eye.2015.48; published online 17 April 2015 Since the online publication of the above article, the authors have noted that the name of the ninth author was published incorrectly. The correct name is SP Kelly. The authors have also noted that the conflict of interest statements were not complete.

The use of intravitreal vascular endothelial growth factor (VEGF) inhibitor medications has widened considerably to include indications affecting females of reproductive age. We present our experiences following intravitreal injection of bevacizumab during the first trimester of unrecognised pregnancies in four women. All our patients were inadvertently exposed to bevacizumab within the first trimester when placental growth and fetal organogenesis take place. There were three cases of pregnancy without complication and one case of complicated pregnancy in which there was a significant past obstetric history. This case series provides further insights into intravitreal injection of bevacizumab in early pregnancy. There is insufficient information to suggest that such use is safe, nor is there definitive evidence to suggest that it causes harm. We advise that ophthalmologists discuss pregnancy with women of childbearing age undergoing intraocular anti-VEGF injections. Should a woman become pregnant, counselling is needed to explain the potential risks and benefits, and the limited available data relating to the use of these agents in early pregnancy.

Introduction and aims The use of ‘poppers’ (volatile alkyl nitrites) has been associated with the development of visual symptoms secondary to the development of maculopathy. There are currently no data regarding the prevalence of this condition among poppers users. The aim of this study was to quantify the presence of visual symptoms among poppers users from a global cohort. Design and methods The Global Drug Survey (GDS) conducts annual anonymous online surveys of drug and alcohol use. Within the 2012 GDS, questions were inserted regarding the presence of visual symptoms in poppers users. Results The GDS received a total of 21 575 valid responses, with a total of 17 479 from the UK, Australia, USA and Eurozone. Within these areas, 5152 (29.5%) had used poppers within their lifetime and 1322 (7.6%) within the previous year. Of the ‘last year’ users, when asked the question: ‘Do you think poppers use has affected your eyesight?’, 29 (2.2%) people responded ‘yes’, 130 (10.0%) responded ‘maybe’ and 1146 (87.8%) responded ‘no (17 people did not answer). Both multiple choice and free-text responses regarding the nature of visual symptoms correlated with the central visual disturbance that would be expected from maculopathy. There was significant increased symptom prevalence with age (likelihood ratio (χ 2 )=19.0; p Discussion and conclusions This study demonstrates that a small, yet significant from a public health perspective, proportion of poppers users have visual symptoms. Clinical correlation is required to determine whether these reported symptoms are due to poppers associated maculopathy, or an alternative cause.

The neural processing of biological motion (BM) is of profound experimental interest since it is often through the movement of another that we interpret their immediate intentions. Neuroimaging points to a specialized cortical network for processing biological motion. Here, high-density electrical mapping and source-analysis techniques were employed to interrogate the timing of information processing across this network. Participants viewed point-light-displays depicting standard body movements (e.g. jumping), while event-related potentials (ERPs) were recorded and compared to ERPs to scrambled motion control stimuli. In a pair of experiments, three major phases of BM-specific processing were identified: 1) The earliest phase of BM-sensitive modulation was characterized by a positive shift of the ERP between 100 and 200 ms after stimulus onset. This modulation was observed exclusively over the right hemisphere and source-analysis suggested a likely generator in close proximity to regions associated with general motion processing (KO/hMT). 2) The second phase of BM-sensitivity occurred from 200 to 350 ms, characterized by a robust negative-going ERP modulation over posterior middle temporal regions bilaterally. Source-analysis pointed to bilateral generators at or near the posterior superior temporal sulcus (STS). 3) A third phase of processing was evident only in our second experiment, where participants actively attended the BM aspect of the stimuli, and was manifest as a centro-parietal positive ERP deflection, likely related to later cognitive processes. These results point to very early sensory registration of biological motion, and highlight the interactive role of the posterior STS in analyzing the movements of other living organisms.