Search

PURPOSE: The objective is to assess associations between visual function and on-road driving performance evaluated by a certified driving rehabilitation specialist (CDRS). METHODS: Adults aged 70 and older enrolled and completed assessments of visual acuity, contrast sensitivity, visual processing speed, visual field sensitivity, motion perception, and spatial ability. At follow-up, on-road driving performance was evaluated on a 15-mile route. Age-adjusted odds ratios and 95% confidence intervals (95% CIs) were used to associate worse CDRS composite score and CDRS global rating for those with worse visual function compared to those with better. RESULTS: For the 144 participants who enrolled, completed vision testing, and the on-road driving evaluation, the mean age was 79.2 (5.1) and 45.8% were female. The odds of worse CDRS global rating and composite score were significantly associated with moderately and severely impaired visual processing speed under divided attention (all p

Background Age-related macular degeneration (AMD), a leading cause of irreversible vision impairment in the United States and globally, is a disease of the photoreceptor support system involving the retinal pigment epithelium (RPE), Bruch’s membrane, and the choriocapillaris in the setting of characteristic extracellular deposits between outer retinal cells and their blood supply. Research has clearly documented the selective vulnerability of rod photoreceptors and rod-mediated (scotopic) vision in early AMD, including delayed rod-mediated dark adaptation (RMDA) and impaired rod-mediated light and pattern sensitivity. The unifying hypothesis of the Alabama Study on Early Macular Degeneration (ALSTAR2) is that early AMD is a disease of micronutrient deficiency and vascular insufficiency, due to detectable structural changes in the retinoid re-supply route from the choriocapillaris to the photoreceptors. Functionally this is manifest as delayed rod-mediated dark adaptation and eventually as rod-mediated visual dysfunction in general. Methods A cohort of 480 older adults either in normal macular health or with early AMD will be enrolled and followed for 3 years to examine cross-sectional and longitudinal associations between structural and functional characteristics of AMD. Using spectral domain optical coherence tomography, the association between (1) subretinal drusenoid deposits and drusen, (2) RPE cell bodies, and (3) the choriocapillaris’ vascular density and rod- and cone-mediated vision will be examined. An accurate map and timeline of structure-function relationships in aging and early AMD gained from ALSTAR2, especially the critical transition from aging to disease, will identify major characteristics relevant to future treatments and preventative measures. Discussion A major barrier to developing treatments and prevention strategies for early AMD is a limited understanding of the temporal interrelationships among structural and functional characteristics while transitioning from aging to early AMD. ALSTAR2 will enable the development of functionally valid, structural biomarkers for early AMD, suitable for use in forthcoming clinical trials as endpoint/outcome measures. The comprehensive dataset will also allow hypothesis-testing for mechanisms that underlie the transition from aging to AMD, one of which is a newly developed Center-Surround model of cone resilience and rod vulnerability. Trial registration ClinicalTrials.gov Identifier NCT04112667, October 7, 2019.

Purpose To describe the progression and regression of individual subretinal drusenoid deposits (SDDs) and surrounding photoreceptors and retina in patients with age-related macular degeneration (AMD) over a 3.5-year period using multimodal imaging including adaptive optics scanning laser ophthalmoscopy (AOSLO). Design Longitudinal observational study. Participants Four patients with intermediate AMD. Methods Six eyes of 4 patients with intermediate AMD each were imaged 4 times over 3.5 years. Five eyes of 3 patients showed only SDD and no drusen. Subretinal drusenoid deposit presence and progression were assessed by multimodal imaging and a 3-stage grading system based on spectral-domain (SD) OCT. Morphologic features and the fine structure of individual SDD lesions identified at baseline were examined by AOSLO at follow-up visits. Reflectivity of photoreceptors surrounding SDD were assessed with AOSLO and SD OCT. Main Outcome Measures Morphologic features, fine structure, and size of individual SDD lesions by AOSLO; photoreceptor integrity surrounding SDD via AOSLO and SD OCT; and retinal layer thicknesses via SD OCT. Results Individual SDDs followed independent lifecycle trajectories, exhibiting growth, shrinkage, fusion, and disappearance. Alterations in shape, morphologic features, and internal structure were not obviously the result of the presence of invading phagocytes. Of 822 lesions across all stages examined at baseline, 566 (69%) grew, 123 (15%) shrank, 47 (6%) remained of similar size, 86 (11%) disappeared, and 5 (0.6%) reappeared after regression. A return of characteristic photoreceptor reflectivity in AOSLO (punctate) and in SD OCT (prominent ellipsoid zone) was observed after regression of some SDD in 5 eyes of 4 patients. All eyes exhibited thinning of photoreceptor layers, despite intact retinal pigment epithelium (RPE), to approximately 70% of baseline thicknesses, as well as poorly visible or undetectable outer retinal bands. Conclusions Adaptive optics scanning laser ophthalmoscopy and SD OCT imaging of individual SDDs over 3.5 years revealed independent trajectories of progression and regression, believed to reflect the activities of local outer retinal cells. Restoration of some photoreceptor reflectivity and intact RPE after SDD regression should be seen in the larger context of outer retinal atrophy, previously suggested as a new form of advanced AMD, and herein replicated.

Background Older drivers have a crash rate nearly equal to that of young drivers whose crash rate is the highest among all age groups. Contrast sensitivity impairment is common in older adults. The purpose of this study is to examine whether parameters from the photopic and mesopic contrast sensitivity functions (CSF) are associated with incident motor vehicle crash involvement by older drivers. Methods This study utilized data from older drivers (ages ≥60 years) who participated in the Strategic Highway Research Program Naturalistic Driving Study, a prospective, population-based study. At baseline participants underwent photopic and mesopic contrast sensitivity testing for targets from 1.5–18 cycles per degree. Model fitting generated area under the log CSF (AULCSF) and peak log sensitivity. Participant vehicles were instrumented with sensors that captured continuous driving data when the vehicle was operating (accelerometers, global positioning system, forward radar, 4-channel video). They participated for 1–2 years. Crashes were coded from the video and other data streams by trained analysts. Results The photopic analysis was based on 844 drivers, and the mesopic on 854 drivers. Photopic AULCSF and peak log contrast sensitivity were not associated with crash rate, whether defined as all crashes or at-fault crashes only (all p > 0.05). Mesopic AULCSF and peak log sensitivity were associated with an increased crash rate when considered for all crashes (rate ratio (RR): 1.36, 95% CI: 1.06–1.72; RR: 1.28, 95% CI: 1.01–1.63, respectively) and at-fault crashes only (RR: 1.50, 95% CI: 1.16–1.93; RR: 1.38, 95% CI: 1.07–1.78, respectively). Conclusions Results suggest that photopic contrast sensitivity testing may not help us understand future crash risk at the older-driver population level. Results highlight a previously unappreciated association between older adults’ mesopic contrast sensitivity deficits and crash involvement regardless of the time of day. Given the wide variability of light levels encountered in both day and night driving, mesopic vision tests, with their reliance on both cone and rod vision, may be a more comprehensive assessment of the visual system’s ability to process the roadway environment.

Subretinal drusenoid deposits (SDD) first appear in the rod-rich perifovea and can extend to the cone-rich fovea. To refine the spatial relationship of visual dysfunction with SDD burden, we determined the topography of mesopic and scotopic light sensitivity in participants with non-neovascular AMD with and without SDD.Thirty-three subjects were classified into three groups: normal (n = 9), AMD-Drusen (with drusen and without SDD; n = 12), and AMD-SDD (predominantly SDD; n = 12). Mesopic and scotopic microperimetry were performed using 68 targets within the Early Treatment Diabetic Retinopathy Study grid, including points at 1.7° from the foveal center (rod:cone ratio, 0.35). Age-adjusted linear regression was used to compare mesopic and scotopic light sensitivities across groups.Across the entire Early Treatment Diabetic Retinopathy Study grid and within individual subfields, the three groups differed significantly for mesopic and scotopic light sensitivities (all P0.05). The AMD-SDD group exhibited significantly decreased mesopic and scotopic sensitivity versus both the normal and the AMD-Drusen groups (all P0.05), while AMD-Drusen and normal eyes did not significantly differ (all P0.05). The lowest relative sensitivities were recorded for scotopic light levels, especially in the central subfield, in the AMD-SDD group.SDD-associated decrements in rod-mediated vision can be detected close to the foveola, and these deficits are proportionately worse than functional loss in the rod-rich perifovea. This finding suggests that factors other than the previously hypothesized direct cytotoxicity to photoreceptors and local transport barrier limitations may negatively impact vision. Larger prospective studies are required to confirm these observations.

PURPOSE The purpose was to identify factors associated with older glaucoma patients' knowledge of, perceptions of, and predispositions for telemedicine use. MATERIALS AND METHODS Established patients age 60 years and above with a diagnosis of primary open-angle glaucoma, glaucoma suspect, or ocular hypertension followed by a glaucoma fellowship-trained ophthalmologist were enrolled in the study at an academic, urban, tertiary referral eye clinic. Enrolled patients were administered a Life Space Questionnaire (LSQ), scored 0 to 9, and Preferences for Telemedicine Questionnaire (PTQ), a Likert scale validated tool. χ testing analyzed PTQ responses by age, race, education, employment status, LSQ score, and distance traveled from home address to clinic. A Mann-Whitney U test was used to compare PTQ responses by visual field index and visual acuity for the better and worse eye. RESULTS Of 110 patients enrolled, 71% of patients agreed or were neutral to receiving telediagnosis and 74% of patients agreed or were neutral to receiving teleintervention. Patients aged 60 to 69 years compared with those 70 and above had significantly greater knowledge about types of telemedicine: telediagnosis (53% vs. 31%, P=0.02), teleintervention (49% vs. 24%, P=0.006), teletriage (80% vs. 47%, P=0.0004), and telemonitoring (55% vs. 27%, P=0.003). Patients of European descent had significantly more knowledge about teletriage compared with those of non-European descent (72% vs. 53%, P=0.04). Patients with more education (>high school) compared with those with less education (≤high school) had more knowledge about telemedicine (39% vs. 16%, P=0.007) and all the uses of it: telediagnosis (61% vs. 45%, P

Purpose To examine the association between sequence variants in genetic risk factors for age-related macular degeneration (AMD) and delayed rod-mediated dark adaptation (RMDA), the first functional biomarker for incident AMD, in older adults with normal macular health and early AMD. Design Cross-sectional. Participants Adults 60 years of age or older showing normal macular health (defined as both eyes at step 1 on the Age-Related Eye Disease Study 9-step AMD classification system) and those with AMD in one or both eyes (defined as steps 2–9). Methods Single nucleotide polymorphisms were genotyped in the complement factor H (CFH) and ARMS2 genes using a Taqman assay. Rod-mediated dark adaptation was assessed in 1 eye after photobleach with targets centered at 5° on the inferior vertical meridian. Rate of dark adaptation was defined by rod intercept time (RIT), duration (in minutes) required for sensitivity to reach a criterion sensitivity level in the latter half of the second component of rod recovery. Associations between CFH and ARMS2 polymorphisms and RMDA were adjusted for age and smoking. Main Outcome Measure Rod intercept time. Results The sample consisted of 543 participants having both genotype and RIT determination; 408 showed normal macular health and 135 demonstrated AMD, most having early AMD (124 of 135). For the combined sample, higher RIT (slower RMDA) was observed for both the A69S variant in ARMS2 and the Y402H variant in CFH (adjusted P = 0.0001 and P = 0.0023, respectively). For healthy participants, the A69S variant in ARMS2 was associated with higher RIT (adjusted P = 0.0011), whereas the Y402H variant in CFH was not (adjusted P = 0.2175). For AMD patients, the A69S variant of ARMS2 and the Y402H variant of CFH were associated with higher RIT (adjusted P = 0.0182 and P = 0.0222, respectively). Those with a larger number of high-risk ARMS2 and CFH alleles showed higher RIT, in both healthy and AMD groups (adjusted P = 0.0002 and P Conclusions We report a novel association wherein older adults with high-risk ARMS2 and CFH genotypes are more likely to demonstrate delayed RMDA, the first functional biomarker for incident early AMD. Before the AMD clinical phenotype is present, those showing normal macular health with the ARMS2 A69S allele demonstrate delayed RMDA. Understanding ARMS2 function is a research priority.

Background This study aimed to evaluate the association between a Certified Driving Rehabilitation Specialist's (CDRS) ratings of on-road driving performance by older drivers and at-fault crash and near-crash involvement using naturalistic driving techniques where crashes and near-crashes are recorded in everyday driving through in-vehicle instrumentation. Methods This is a cohort study of 144 drivers aged 70 years and over who were recruited due to a recent ophthalmology clinic visit at the University of Alabama at Birmingham. Baseline measurements consisted of demographics, visual status, and other health variables. At-fault crashes and near-crashes over 6 months were identified through instrumentation placed in their personal vehicle that recorded vehicle kinematics and video. After 6 months, a CDRS completed an on-road assessment and provided a composite rating on specific driving behaviors and a global score. Results Rate ratios examining the association between older drivers with worse CDRS composite scores and rates of at-fault crashes, at-fault near-crashes, and combined at-fault crashes and near-crashes were significantly higher compared to drivers with better scores. Results were similar for the CDRS global score. Conclusions Motor vehicle administrations use CDRS ratings to make decisions about licensure, and in clinical programs such as those based at rehabilitation clinics use them to make recommendations about fitness to drive and rehabilitation. This study suggests that these decisions and recommendations are valid from a safety standpoint.

Importance Government motor vehicle crash reports used in the study of driver safety can be biased and incomplete. Naturalistic driving methods using in-vehicle instrumentation have been developed in recent years to objectively measure crashes and near crashes as they occur on the road using video and vehicle kinematic data. Objective To examine visual risk factors associated with at-fault crashes and near crashes among older drivers, most of whom have age-related eye conditions associated with vision impairment. Design, setting, and participants This prospective cohort study was conducted at an academic ophthalmology clinic from January 1, 2015, to November 10, 2018, among 154 adults 70 years of age or older who were legally licensed in Alabama and who reported currently driving at least 4 days per week; 137 of 151 participants (90.7%) had an age-related eye condition in at least 1 eye. Drivers participated in a baseline visual function assessment followed by installation of a data acquisition system recording multichannel synchronized video and vehicle kinematics in their personal vehicle. Drivers were instructed to drive for 6 months as they normally would during everyday life. Statistical analysis was performed from June 15 to September 15, 2020. Main outcomes and measures The rate of combined incident at-fault crashes and near crashes, defined by the number of events and the number of miles driven. Results The sample consisted of 154 drivers (85 men [55.2%]; mean [SD] age, 79.3 [5.1] years). Visual functions associated with crash and near-crash involvement included impaired contrast sensitivity (rate ratio [RR], 2.7; 95% CI, 1.3-5.5), moderate (RR, 2.3; 95% CI, 1.1-4.9) and severe (RR, 5.0; 95% CI, 2.2-11.7) slowing in visual processing speed, and elevated motion perception thresholds for a drifting grating (RR, 1.9; 95% CI, 1.1-3.5). Those with impaired peripheral visual field sensitivity had increased rates of crashes and near crashes (RR, 1.8; 95% CI, 1.0-3.3); however, this finding was not statistically significant (P = .07). Conclusions and relevance With the use of naturalistic driving methods in which crashes and near crashes involving older drivers are objectively measured as they occur on the road, associations have been identified between impaired contrast sensitivity, slowed visual processing speed, and impaired motion perception and an increased rate of a combined total of at-fault crashes and near crashes.

Purpose We assessed the association between the abundance of macular xanthophyll carotenoid pigment using dual-wavelength autofluorescence and multimodal vision testing including rod-mediated dark adaptation (RMDA), a measure of retinoid re-supply, in adults ≥60 years old with and without age-related macular degeneration (AMD). Methods AMD severity was determined using the nine-step Age-Related Eye Disease Study grading. Tests probed cones (best-corrected visual acuity, contrast sensitivity), cones and rods (low-luminance visual acuity, low-luminance deficit, mesopic light sensitivity), or rods only (scotopic light sensitivity, RMDA). Signal attenuation by macular pigment optical density (MPOD) was estimated using a ratio of blue and green autofluorescence signal to yield mean MPOD in a 1°-diameter fovea-centered disk, mean MPOD in a 2°-diameter disk centered on a perifoveal RMDA test location, and macular pigment optical volume (MPOV, or integrated MPOD) in a 4°-diameter fovea-centered disk. Age-adjusted associations between vision and imaging measures were determined. Results In 88 eyes of 88 subjects (age, 74.9 ± 5.8 years) with normal eyes (n = 32), early AMD (n = 23), or intermediate AMD (n = 33), foveal and perifoveal MPOD and MPOV were higher in the AMD eyes than in the normal eyes. At the RMDA test location, higher MPOD was unrelated to AMD severity but was associated with faster RMDA. Conclusions In older adults with and without AMD, higher macular xanthophyll concentrations are associated with better best-corrected visual acuity and RMDA. Data are consistent with a model of cone resilience and rod vulnerability in aging and AMD and can be further explored in a larger sample study.

Luminance contrast is the fundamental building block of human spatial vision. Therefore contrast sensitivity, the reciprocal of contrast threshold required for target detection, has been a barometer of human visual function. Although retinal ganglion cells (RGCs) are known to be involved in contrast coding, it still remains unknown whether the retinal layers containing RGCs are linked to a person's contrast sensitivity (e.g., Pelli-Robson contrast sensitivity) and, if so, to what extent the retinal layers are related to behavioral contrast sensitivity. Thus the current study aims to identify the retinal layers and features critical for predicting a person's contrast sensitivity via deep learning.Data were collected from 225 subjects including individuals with either glaucoma, age-related macular degeneration, or normal vision. A deep convolutional neural network trained to predict a person's Pelli-Robson contrast sensitivity from structural retinal images measured with optical coherence tomography was used. Then, activation maps that represent the critical features learned by the network for the output prediction were computed.The thickness of both ganglion cell and inner plexiform layers, reflecting RGC counts, were found to be significantly correlated with contrast sensitivity (r = 0.26 ∼ 0.58, Ps0.001 for different eccentricities). Importantly, the results showed that retinal layers containing RGCs were the critical features the network uses to predict a person's contrast sensitivity (an average R2 = 0.36 ± 0.10).The findings confirmed the structure and function relationship for contrast sensitivity while highlighting the role of RGC density for human contrast sensitivity.

Importance Case series have identified a macular condition hypothesized to be associated with the use of pentosan polysulfate sodium (PPS). Observational studies seeking to quantify this association have yielded equivocal results. Objective To estimate the association between PPS exposure and maculopathy. Design, Setting, and Participants This disproportionality analysis was conducted using the US Food and Drug Administration Adverse Event Reporting System from January 2013 through June 2020. Exposure Adverse event reports for pentosan polysulfate were selected and compared with adverse event reports associated with drugs taken for the following indications: interstitial cystitis, cystitis, bladder disorder, or bladder pain. Main Outcome Measures Retinal adverse events were identified using the retinal disorders Standardized Medical Dictionary for Regulatory Activities (MedDRA) Query, which includes conditions associated with retinal damage attributable to blockage of its blood supply, nutritional deficiencies, toxins, and diseases affecting the retina. Results There were 2775 reports available for analysis in the PPS group (of which 1966 were for women [70.9%]) and 6833 reports in the other drugs group (of which 4036 [59.1%] were for women). The proportion of adverse events for any macular event relative to all other events was elevated for the users of PPS compared with those using other interstitial cystitis and bladder pain drugs (proportionate reporting ratio [PRR], 1.21 [95% CI, 1.01-1.44]). With respect to specific retinal conditions, macular degeneration (20 [0.8%] vs 15 [0.2%]), maculopathy (83 [3.4%] vs 2 [0.03%]), retinal dystrophy (3 [0.1%] vs 0), retinal injury (5 [0.2%] vs 0), and retinal toxicity (3 [0.1%] vs 0) were proportionately more common among users of PPS compared with those using other interstitial cystitis and bladder pain drugs, respectively. Conclusions and Relevance The results of the current study add to the growing evidence that PPS use is associated with an increased risk of maculopathy. Studies that rule out prevalent retinal abnormalities prior to the initiation of PPS would strengthen the current body of literature.

PURPOSE: To examine the association between macular pigment optical density (MPOD) and rod-mediated dark adaptation (RMDA) in persons ≥60 years old with normal maculas as determined by an accepted color fundus photography grading system. METHODS: This cross-sectional analysis used baseline data from eyes in the Alabama Study on Early Age-Related Macular Degeneration. Eyes at step 1 in the AREDS 9-step grading system were considered normal. Eyes were additionally assessed by spectral domain optical coherence tomography (SD-OCT). Foveal MPOD was estimated via heterochromatic flicker photometry, and RMDA was assessed with a computerized dark adaptometer. The association between RMDA and MPOD was examined via Spearman correlation coefficients adjusted for age. RESULTS: In 306 eyes from 306 persons (mean age 68.2 years) in normal macular health, MPOD was not associated with RMDA (age-adjusted rank correlation = 0.043, p = 0.45). After 81 eyes with incidental macular findings by SD-OCT evaluation were excluded, the association between MPOD and RMDA remained null (N=225, age-adjusted r=0.015, p=0.82). CONCLUSION: In a large sample of normal aged eyes, RMDA, a visual function that is rate-limited by retinoid availability to photoreceptors across the complex of retinal pigment epithelium, Bruch’s membrane, and choriocapillaris, is not related to MPOD in the neurosensory retina.

Purpose To explore differences in driving performance of older adults with age-related macular degeneration (AMD) and age-matched controls, and to identify the visual determinants of driving performance in this population. Methods Participants included 33 older drivers with AMD (mean age [M] = 76.6 ± 6.1 years; better eye Age-Related Eye Disease Study grades: early [61%] and intermediate [39%]) and 50 age-matched controls (M = 74.6 ± 5.0 years). Visual tests included visual acuity, contrast sensitivity, visual fields, and motion sensitivity. On-road driving performance was assessed in a dual-brake vehicle by an occupational therapist (masked to drivers' visual status). Outcome measures included driving safety ratings (scale of 1–10, where higher values represented safer driving), types of driving behavior errors, locations at which errors were made, and number of critical errors (CE) requiring an instructor intervention. Results Drivers with AMD were rated as less safe than controls (4.8 vs. 6.2; P = 0.012); safety ratings were associated with AMD severity (early: 5.5 versus intermediate: 3.7), even after adjusting for age. Drivers with AMD had higher CE rates than controls (1.42 vs. 0.36, respectively; rate ratio 3.05, 95% confidence interval 1.47–6.36, P = 0.003) and exhibited more observation, lane keeping, and gap selection errors and made more errors at traffic light–controlled intersections (P < 0.05). Only motion sensitivity was significantly associated with driving safety in the AMD drivers (P = 0.005). Conclusions Drivers with early and intermediate AMD can exhibit impairments in their driving performance, particularly during complex driving situations; motion sensitivity was most strongly associated with driving performance. These findings have important implications for assessing the driving ability of older drivers with visual impairment.

Purpose Binocular summation refers to better visual performance with two eyes than with one eye. Little is known about the mechanism underlying binocular contrast summation in patients with common eye diseases who often exhibit binocularly asymmetric vision loss and structural changes along the visual pathway. Here we asked whether the mechanism of binocular contrast summation remains preserved in eye disease. Methods This study included 1035 subjects with normal ocular health, cataract, age-related macular degeneration, glaucoma, and retinitis pigmentosa. Monocular and binocular contrast sensitivity were measured by the Pelli-Robson contrast sensitivity chart. Interocular ratio (IOR) was quantified as the ratio between the poorer and better eye contrast sensitivity. Binocular summation ratio (BSR) was quantified as the ratio between binocular and better eye contrast sensitivity. Results All groups showed statistically significant binocular summation, with the BSR ranging from 1.25 [1.20, 1.30] in the glaucoma group to 1.31 [1.27, 1.36] in the normal vision group. There was no significant group difference in the BSR, after accounting for IOR. By fitting a binocular summation model Binocular = (Leftm + Rightm)1/m to the contrast sensitivity data, we found that the same binocular summation rule, reflected by the parameter m, applies across the five groups. Conclusions Cortical binocular contrast summation appears to be preserved in spite of eye diseases that can affect the two eyes differently. This finding supports the importance of assessing both monocular and binocular functions, rather than relying on a monocular assessment in the better eye as a potentially inaccurate surrogate measure.

Glaucoma is a leading cause of vision loss and blindness in the U.S. Risk factors include African American race, older age, family history of glaucoma, and diabetes. This paper describes the evaluation of a mobile eye health and a telemedicine program designed to improve access to eye care among people at high-risk for glaucoma.The RE-AIM (reach, efficacy, adoption, implementation, and maintenance) evaluation framework was used to harmonize indicators. Both programs provided community-based eye health education and eye services related to glaucoma detection and care. Each program reported data on participants and community partners. An external evaluator conducted site visit interviews with program staff and community partners. Quantitative and qualitative data were integrated and analyzed using the RE-AIM dimensions.By targeting high-risk populations and providing comprehensive eye exams, both programs detected a large proportion of new glaucoma-related cases (17-19%) - a much larger proportion than that found in the general population (2%). The educational intervention increased glaucoma knowledge; evidence that it led people to seek eye care was inconclusive.Evaluation findings from the mobile eye health program and the telemedicine program may provide useful information for wider implementation in public health clinics and in optometrist clinics located in retail outlets.

Background. Smoking causes blindness-related diseases. Eye-care providers are uniquely positioned to help their patients quit smoking. Aims. Using a pre-/postevaluation design, this study evaluated a web-based training in smoking cessation counseling targeting eye-care providers. Method. The training was developed based on the 3A1R protocol: “Ask about smoking, Advise to quit, Assess willingness to quit, and Refer to tobacco quitlines,” and made available in the form of a web-based video presentation. Providers ( n = 654) at four academic centers were invited to participate. Participants completed pretraining, posttraining, and 3-month follow-up surveys. Main outcomes were self-reported improvement in their motivation, confidence, and counseling practices at 3-month follow-up. Generalized linear mixed models for two time-points (pretraining and 3-month) were conducted for these outcomes. Results. A total of 113 providers (54.0% males) participated in the study (17.7% response rate). At the 3-month evaluation, 9.8% of participants reported improvement in their motivation. With respect to the 3A1R, 8% reported improvement in their confidence for Ask, 15.5% for Advise, 28.6% for Assess, and 37.8% for Refer. Similarly, 25.5% reported improvement in their practices for Ask, 25.5% for Advise, 37.2% for Assess, and 39.4% for Refer to tobacco quitlines ( p < .001 for all except for Refer confidence p = .05). Discussion. Although participation rate was low, the program effectively improved providers’ smoking cessation counseling practices. Conclusions. Including training in smoking cessation counseling in ophthalmology curriculums, and integrating the 3A1R protocol into the electronic medical records systems in eye-care settings, might promote smoking cessation practices in these settings.

Purpose To examine if racial differences in Bruch's membrane opening minimum rim width (BMO-MRW) in spectral-domain optical coherence tomography (SDOCT) exist, specifically between people of African descent (AD) and European descent (ED) in normal ocular health. Design Cross-sectional study. Methods Patients presenting for a comprehensive eye examination at retail-based primary eye clinics were enrolled based on ≥1 of the following at-risk criteria for glaucoma: AD aged ≥40 years, ED aged ≥50 years, diabetes, family history of glaucoma, and/or pre-existing diagnosis of glaucoma. Participants with normal optic nerves on examination received SDOCT of the optic nerve head (24 radial scans). Global and regional (temporal, superotemporal, inferotemporal, nasal, superonasal, and inferonasal) BMO-MRW were measured and compared by race using generalized estimating equations. Models were adjusted for age, sex, and BMO area. Results SDOCT scans from 269 eyes (148 participants) were included in the analysis. Mean global BMO-MRW declined as age increased. After adjusting for age, sex, and BMO area, there was not a statistically significant difference in mean global BMO-MRW by race ( P = .60). Regionally, the mean BMO-MRW was lower in the crude model among AD eyes in the temporal, superotemporal, and nasal regions and higher in the inferotemporal, superonasal, and inferonasal regions. However, in the adjusted model, these differences were not statistically significant. Conclusions BMO-MRW was not statistically different between those of AD and ED. Race-specific normative data may not be necessary for the deployment of BMO-MRW in AD patients.

PURPOSE: Hyperreflective foci (HRF) are optical coherence tomography (OCT) biomarkers for progression of non-neovascular age-related macular degeneration (AMD) attributed to anteriorly migrated retinal pigment epithelial (RPE) cells. We examined associations between rod- and cone-mediated vision and HRF plus smaller hyperreflective specks (HRS); we sought a histologic candidate for HRS. DESIGN: cross-sectional study; histologic survey PARTICIPANTS: Patients with normal maculas (n=34), early AMD (N=26), and intermediate AMD (N=41) METHODS: AMD severity was determined via the 9-step Age-Related Eye Disease Study scale. In OCT scans HRF and HRS were manually counted. Vision tests probed cones (best corrected visual acuity (VA), contrast sensitivity), mixed cones and rods (low luminance VA, low luminance deficit, mesopic light sensitivity), or rods (scotopic light sensitivity, rod-mediated dark adaptation (RMDA)). An online AMD histopathology resource was reviewed. MAIN OUTCOME MEASURES: Vision in eyes assessed for HRF and HRS; candidate histology for HRS. RESULTS: In 101 eyes of 101 patients, HRF and HRS were identified in 25 and 95 eyes, respectively, with good intra- and inter-rater reliability. HRF were present but sparse in normal eyes, infrequent in early AMD eyes, and frequent but highly variable among intermediate AMD eyes (number per eye, 0.1±0.2, 0.2±0.5, 1.9 ± 3.4; normal, early, intermediate, respectively). HRS outnumbered HRF in all groups (4.5 ± 3.2; 6.3±5.8; 19.4 ± 22.4). Delayed RMDA was strongly associated with more HRF and HRS (both p

Purpose To evaluate the relationship between visual function and a five-year history of motor vehicle collision rates in older adults. Motion perception impairment was explored as a risk factor for motor vehicle collisions for the first time in this study. Materials and methods Participants were licensed drivers ≥70 years old enrolled in the Alabama VIP Older Driver Study who underwent functional assessments for motion perception, distance visual acuity, contrast sensitivity, visual field sensitivity, and visual processing speed. Participants were recruited based on their being patients in an ophthalmology clinic in the year prior to enrollment or had participated in an earlier driving study. Crash reports were obtained from the Alabama Law Enforcement Agency for the 5 years prior to enrollment and mileage estimated using the Driving Habits Questionnaire. Crude and age-adjusted rate ratios (RRs) and 95 % confidence intervals (95 % CIs) were calculated using Poisson regression. Results 159 participants enrolled with a mean age of 79 years. The age-adjusted crash rate was higher among those with worse motion perception (RR: 2.7, 95 % CI: 1.4−5.2), severe slowing in visual processing speed (RR: 3.6, 95 % CI: 1.5−8.5), and impaired peripheral visual field sensitivity (RR: 2.4, 95 % CI: 1.3−4.4). Conclusions Among a sample of older drivers, crash rates were higher for those with impaired motion perception, severely slowed visual processing speed, and impaired peripheral visual field sensitivity. The association between motion perception and crash risk in older drivers has not been previously reported. Prospective analysis of the Alabama VIP Older Driver Study will examine these risk factors for future collision involvement based on naturalistic driving data.

Purpose To refine estimates of macular soft drusen abundance in eyes with age-related macular degeneration (AMD) and evaluate hypotheses about drusen biogenesis, we investigated topographic distribution and growth rates of drusen by optical coherence tomography (OCT). We compared results to retinal features with similar topographies (cone density and macular pigment) in healthy eyes. Methods In a prospective study, distribution and growth rates of soft drusen in eyes with AMD were identified by human observers in OCT volumes and analyzed with computer-assistance. Published histologic data for macular cone densities (n = 12 eyes) and in vivo macular pigment optical density (MPOD) measurements in older adults with unremarkable maculae (n = 31; 62 paired eyes, averaged) were revisited. All values were normalized to Early Treatment Diabetic Retinopathy Study (ETDRS) subfield areas. Results Sixty-two eyes of 44 patients were imaged for periods up to 78 months. Soft drusen volume per unit volume at baseline is 24.6-fold and 2.3-fold higher in the central ETDRS subfield than in outer and inner rings, respectively, and grows most prominently there. Corresponding ratios (central versus inner and central versus outer) for cone density in donor eyes is 13.3-fold and 5.1-fold and for MPOD, 24.6 and 23.9-fold, and 3.6 and 3.6-fold. Conclusions Normalized soft drusen volume in AMD eyes as assessed by OCT is ≥ 20-fold higher in central ETDRS subfields than in outer rings, paralleling MPOD distribution in healthy eyes. Data on drusen volume support this metric for AMD risk assessment and clinical trial outcome measure. Alignment of different data modalities support the ETDRS grid for standardizing retinal topography in mechanistic studies of drusen biogenesis.

Purpose To compare patient-centered outcomes in patients with proliferative diabetic retinopathy (PDR) treated with ranibizumab vs panretinal photocoagulation (PRP). Design Randomized clinical trial. Methods Setting: Multicenter (55 U.S. sites). Patient Population: Total of 216 adults with 1 study eye out of 305 adults (excluding participants with 2 study eyes, because each eye received a different treatment) with PDR, visual acuity 20/320 or better, no history of PRP. Intervention: Ranibizumab (0.5 mg/0.05 mL) vs PRP. Main Outcome Measures: Change from baseline to 2 years in composite and prespecified subscale scores from the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25), University of Alabama Low Luminance Questionnaire (UAB-LLQ), and Work Productivity and Activity Impairment Questionnaire (WPAIQ). Results For the NEI VFQ-25 and UAB-LLQ composite scores, ranibizumab–PRP treatment group differences (95% CI) were +4.0 (-0.2, +8.3, P = .06) and +1.8 (-3.5, +7.1, P = 0.51) at 1 year, and +2.9 (-1.5, +7.2, P = .20) and +2.3 (-2.9, +7.5, P = .37) at 2 years, respectively. Work productivity loss measured with the WPAIQ was 15.6% less with ranibizumab (-26.3%, −4.8%, P = .005) at 1 year and 2.9% (-12.2%, +6.4%, P = .54) at 2 years. Eighty-three ranibizumab participants (97%) were 20/40 or better in at least 1 eye (visual acuity requirement to qualify for an unrestricted driver's license in many states) at 2 years compared with 82 PRP participants (87%, adjusted risk ratio = 1.1, 95% CI: 1.0, 1.2, P = .005). Conclusions Though differences in some work productivity and driving-related outcomes favored ranibizumab over PRP, no differences between treatment regimens for PDR were identified for most of the other patient-centered outcomes considered.

Background Many studies on vision and driving cessation have relied on measures of sensory function, which are insensitive to the higher-order cognitive aspects of visual processing. The purpose of this study was to examine the association between traditional measures of visual sensory function and higher-order visual processing skills with incident driving cessation in a population-based sample of older drivers. Methods Two thousand licensed drivers aged 70 years or older were enrolled and followed for three years. Tests for central vision and visual processing were administered at baseline and included visual acuity, contrast sensitivity, sensitivity in the driving visual field, visual processing speed (useful field of view [UFOV] Subtest 2 and Trails B) and spatial ability measured by the Visual Closure Subtest of the Motor-free Visual Perception Test. Participants self-reported the month and year of driving cessation and provided a reason for cessation. Cox proportional hazards models were used to generate crude and adjusted hazard ratios with 95% confidence intervals between visual functioning characteristics and risk of driving cessation over a three-year period. Results During the study period, 164 participants stopped driving, which corresponds to a cumulative incidence of 8.5 per cent. Impaired contrast sensitivity, visual fields, visual processing speed (UFOV and Trails B) and spatial ability were significant risk factors for subsequent driving cessation after adjusting for age, gender, marital status, number of medical conditions and miles driven. Visual acuity impairment was not associated with driving cessation. Medical problems (63 per cent), specifically musculoskeletal and neurological problems, as well as visual problems (17 per cent) were cited most frequently as the reason for driving cessation. Conclusion Assessment of cognitive and visual functioning can provide useful information about subsequent risk of driving cessation among older drivers. In addition, a variety of factors, not just vision, influenced the decision to stop driving and may be amenable to intervention.

PURPOSE In older eyes in normal macular health, we examined associations between impaired photopic acuity, mesopic acuity, spatial contrast sensitivity, light sensitivity, and the presence of low luminance deficit (difference between photopic and mesopic acuity) at baseline and incident AMD 3 years later. Associations were compared with an association between delayed rod-mediated dark adaptation and incident AMD, previously reported for this cohort. METHODS Enrollees were 60 years or older. Eyes at step 1 in the AREDS nine-step classification system based on masked grading of color fundus photographs were included. Photopic and mesopic acuity, contrast sensitivity, and light sensitivity, and the presence of low luminance deficit, were measured at baseline. Demographic, lifestyle, general health, and blood markers were assessed at baseline as potential confounders. Three years later fundus grading was repeated to determine AMD presence. RESULTS For the analysis, 827 eyes of 467 persons were eligible. Impaired mesopic acuity at baseline was associated with incident AMD, age-adjusted rate ratio (RR) 1.57 (95% confidence interval [CI] 1.04-2.35), whereas impaired photopic acuity, contrast sensitivity and macular light sensitivity, and the presence of a low luminance deficit were not. The mesopic acuity association was slightly weaker than the association between abnormal dark adaptation and incident AMD (RR 1.85, 95% CI 1.07-3.20). CONCLUSIONS Impaired mesopic acuity in eyes in normal macular health is a risk factor for incident early AMD 3 years later, however, photopic acuity, contrast sensitivity, and light sensitivity, and the presence of a low luminance deficit are not risk factors.

OBJECTIVE: Distracted driving is a major cause of motor vehicle collision (MVC) involvement. Pets have been identified as potential distraction to drivers, particularly in the front. This type of distraction could be worse for those with impairment in the cognitive aspects of visual processing. The purpose of this study is to evaluate the association between driving with pets and rates of motor vehicle collision involvement in a cohort of older drivers. METHODS: A three-year prospective study was conducted in a population-based sample of 2000 licensed drivers aged 70 years and older. At the baseline visit, a trained interviewer asked participants about pet ownership, whether they drive with pets, how frequently, and where the pet sits in the vehicle. Motor vehicle collision (MVC) involvement during the three-year study period was obtained from the Alabama Department of Public Safety. At-fault status was determined by the police officer who arrived on the scene. Participants were followed until the earliest of death, driving cessation, or end of the study period. Poisson regression was used to calculate crude and adjusted rate ratios (RR) examining the association between pet ownership, presence of a pet in a vehicle, frequency of driving with a pet, and location of the pet inside with vehicle with any and at-fault MVC involvement. We examined whether the associations differed by higher order visual processing impairment status, as measured by Useful Field of View, Trails B, and Motor-free Visual Perception Test. RESULTS: Rates of crash involvement were similar for older adults who have ever driven with a pet compared to those who never drove with their pet (RR=1.15, 95% CI 0.76-1.75). Drivers who reported always or sometimes driving with their pet had higher MVC rates compared to pet owners who never drive with a pet, but this association was not statistically significant (RR=1.39, 95% CI 0.86-2.24). In terms of location, those reporting having a pet frequently ride in the front of the vehicle had similar rates of MVC involvement compared to those who did not drive with a pet in the front. A similar pattern of results was observed for at-fault MVCs. This association was not modified by visual processing impairment status. CONCLUSION: The current study demonstrates a positive but non-significant association between frequently driving with pets and MVC involvement. More research is needed, particularly on restraint use and whether the pet was in the car at the time of the crash, to help characterize the public safety benefit of regulations on driving with pets. Keywords: Driver distraction; Language: en

BACKGROUND: The PedsQL 4.0 is a generic health-related quality-of-life (HRQoL) instrument that has been used across many pediatric health conditions. The purpose of this study was to investigate its use in children with vision impairment and to test its ability to distinguish between visually impaired and normally sighted children. METHODS: Children with vision impairment and age-matched controls underwent vision testing, including binocular best-corrected distance visual acuity. They completed the PedsQL 4.0 Generic Core Scale Child Report (ages 8–12) or Teen Report (ages 13–18), as appropriate. Parents completed the Parent Proxy Report in a room separate from their children. Analyses included descriptive statistics, intraclass correlations, t tests, and determination of Cronbach’s α for subscales. RESULTS: A total of 70 study subjects and 44 controls were included. Groups were similar with regard to age, race, and sex. PedsQL 4.0 subscales showed no floor effects; however, some scales had ceiling effects of up to 28% in certain groups. Cronbach’s α was excellent (0.88) for all subscales and reports. PedsQL 4.0 total score for children with vision impairment differed significantly from that for normally sighted children for both age groups and for both parent and child reports. Total score was also significantly associated with visual acuity. Parent and child reports correlated poorly (ICC

Purpose OCT has revealed many details of retinal disease that were not available with older imaging technologies. In eyes of adults older than 60 years with healthy maculas as determined by color fundus photography (CFP) and a validated grading system, we screened for pathologic features using OCT. We also tested visual function to assess potential impact of the observed pathologic features on patients. Design Cross-sectional study. Participants Persons recruited from primary ophthalmology care clinics. Methods Color fundus photographs were assessed by the 9-step Age-Related Eye Disease Study scale. OCT macular volumes of participants at step 1 on the Age-Related Eye Disease Study scale, considered healthy, were reviewed by a retina specialist masked to other participant characteristics. Participants were tested for 6 different cone- and rod-mediated visual functions. Main Outcome Measures Percentage of participants with disorders detected on OCT review and visual function measures. Results In 138 of 984 eyes (14%) considered healthy by CFP, pathologic features were detectable by OCT, with 8.4% having vitreomacular interface disorders. Among the low-prevalence disorders found, 5 eyes (0.5%) showed macular telangiectasia type 2. Relative to eyes lacking detectable chorioretinal pathologic features, eyes with any pathologic features were associated with poorer low-luminance visual acuity and rod-mediated dark adaptation. In eyes with epiretinal membranes, the largest single entity identified (n = 61 [6.2%]), significantly worse visual functions were best-corrected visual acuity (P = 0.0444), low-luminance visual acuity (P = 0.0151), and light sensitivity (central 3° and 9°; P = 0.0035 and P = 0.0097, respectively). Conclusions Macular pathologic features with functional visual implications not identified by clinical examination or CFP are detectable with OCT. Vitreomacular interface disorders often are visually significant and treatable conditions that are visible on OCT, but are easily missed on CFP and clinical examination. Another such condition best seen on OCT is macular telangiectasia type 2, an untreatable disorder for which a clinical trial is in progress. OCT has a potential role in primary eye care clinics to screen for retinal pathologic features, especially in eyes with decreased visual acuity and otherwise normal examination results.

PURPOSE To determine the level of adherence to the American Academy of Ophthalmology preferred practice pattern (PPP) guidelines for quality primary open-angle glaucoma (POAG) and POAG suspect (POAGS) care among retail-based optometrists. METHODS Patients with a diagnosis of POAG or POAGS who participated in a telemedicine pilot project were included. Patients' charts were evaluated for 15 elements of PPP guidelines for glaucoma care. Results were further stratified by number of follow-up visits and diagnosis. RESULTS Of 360 identified patients, 10 elements were documented in over 98%. Documentation of the remaining 5 components was as follows: dilated fundus examination 91.1%, central corneal thickness (CCT) 88.6%, visual field 78.9%, gonioscopy 47.5%, and target intraocular pressure (IOP) 15.6%. in total, 32.8% of patients were seen once, whereas the remaining 67.2% had multiple visits. In patients with multiple visits, providers were more likely to document systemic history (100.0% vs. 97.5%; P=0.0346), review of systems (100.0% vs. 97.5%; P=0.0346), gonioscopy (60.0% vs. 22.0%; P

This article summarizes the presentations and recommendations of the tenth annual American Geriatrics Society and National Institute on Aging Bench-to-Bedside research conference, “Sensory Impairment and Cognitive Decline,” on October 2–3, 2017, in Bethesda, Maryland. The risk of impairment in hearing, vision, and other senses increases with age, and almost 15% of individuals aged 70 and older have dementia. As the number of older adults increases, sensory and cognitive impairments will affect a growing proportion of the population. To limit its scope, this conference focused on sensory impairments affecting vision and hearing. Comorbid vision, hearing, and cognitive impairments in older adults are more common than would be expected by chance alone, suggesting that some common mechanisms might affect these neurological systems. This workshop explored the mechanisms and consequences of comorbid vision, hearing, and cognitive impairment in older adults; effects of sensory loss on the aging brain; and bench-to-bedside innovations and research opportunities. Presenters and participants identified many research gaps and questions; the top priorities fell into 3 themes: mechanisms, measurement, and interventions. The workshop delineated specific research questions that provide opportunities to improve outcomes in this growing population. J Am Geriatr Soc 66:2052–2058, 2018.

Background The purpose of this study was to examine the association between secondary task involvement and risk of crash and near-crash involvement among older drivers using naturalistic driving data. Methods Data from drivers aged ≥70 years in the Strategic Highway Research Program (SHRP2) Naturalistic Driving Study database was utilized. The personal vehicle of study participants was equipped with four video cameras enabling recording of the driver and the road environment. Secondary task involvement during a crash or near-crash event was compared to periods of noncrash involvement in a case-crossover study design. Conditional logistic regression was used to generate odds ratios (ORs) and 95% confidence intervals (CI). Results Overall, engaging in any secondary task was not associated with crash (OR = 0.94, 95% CI 0.68-1.29) or near-crash (OR = 1.08, 95% CI 0.79-1.50) risk. The risk of a major crash event with cell phone use was 3.79 times higher than the risk with no cell phone use (95% CI 1.00-14.37). Other glances into the interior of the vehicle were associated with an increased risk of near-crash involvement (OR = 2.55, 95% CI 1.24-5.26). Other distractions external to the vehicle were associated with a decreased risk of crash involvement (OR = 0.53, 95% CI 0.30-0.94). Interacting with a passenger and talking/singing were not associated with crash or near-crash risk. Conclusions Older drivers should avoid any cell phone use and minimize nondriving-related eye glances towards the interior of the vehicle while driving. Certain types of events external to the vehicle are associated with a reduced crash risk among older drivers.

Importance The prevalence of irreversible vision impairment in the United States is expected to increase by 2050. Vision rehabilitation is the primary treatment option. Clinical trials have established its efficacy in improving quality of life. Yet studies indicate that patients experience many barriers to accessing low-vision care. Objectives To examine the rate of referral for low-vision rehabilitation services by resident and attending ophthalmologists for adults with irreversible vision impairment and to assess the knowledge, attitudes, and beliefs of patients about vision rehabilitation. Design, Setting, and Participants Cross-sectional study with enrollment from June 20, 2016, to January 31, 2017, of 143 adults 18 years or older seen in a publicly funded, comprehensive eye clinic in Jefferson County, Alabama, and having 1 or both eyes with irreversible vision impairment (visual acuity was defined as 20/60 or worse) per the electronic health record. Exposures Demographic characteristics; patient questionnaire on knowledge, attitudes, and beliefs about vision rehabilitation; general cognitive status (Short Orientation-Memory-Concentration test); depressive symptoms (Patient Health Questionnaire-9); health literacy (Rapid Estimate of Adult Literacy in Medicine, Revised [REALM-R]); and self-reported difficulty in everyday activities. Main Outcomes and Measures Proportion of patients with irreversible vision impairment who were referred by ophthalmologists to low-vision rehabilitation services per the electronic health record. Results Of 143 patients enrolled with irreversible vision impairment in 1 or both eyes, the mean (SD) age was 55.4 (11.1) years and 68 (47.6%) were women. Most patients were African American (123 [86.0%]), uninsured (88 [61.5%]), and unemployed (92 [64.3%]); on average, they had normal cognitive status, minor depressive symptoms, and limited health literacy. As noted in the electronic health record, the rate of referral for low-vision rehabilitation services was 11.4% for patients with irreversible bilateral vision impairment (4 of 35 patients) and 1.9% for those with unilateral impairment (2 of 108). Most patients with bilateral (31 of 34 [91.2%]) and unilateral (90 of 97 [92.8%]) impairment indicated that they were bothered by their vision impairment, and most reported difficulty with reading (33 of 34 patients [97.1%] who were bilaterally impaired vs 85 of 104 [81.7%] who were unilaterally impaired). Conclusions and Relevance Results of this study suggest a need to better educate ophthalmologists and residents in ophthalmology about referrals to low-vision rehabilitation services for patients with irreversible vision impairment.

Background Older drivers aged ≥70 years old have among the highest rates of motor vehicle collisions (MVC) compared to other age groups. Driving is a highly visual task, and older adults have a high prevalence of vision impairment compared to other ages. Most studies addressing visual risk factors for MVCs by older drivers utilize vehicle accident reports as the primary outcome, an approach with several methodological limitations. Naturalistic driving research methods overcome these challenges and involve installing a high-tech, unobtrusive data acquisition system (DAS) in an older driver’s own vehicle. The DAS continuously records multi-channel video of driver and roadway, sensor-based kinematics, GPS location, and presence of nearby objects in front of the vehicle, providing an objective measure of driving exposure. In this naturalistic driving study, the purpose is to examine the relationship between vision and crashes and near-crashes, lane-keeping, turning at intersections, driving performance during secondary tasks demands, and the role of front-seat passengers. An additional aim is to compare results of the on-road driving evaluation by a certified driving rehabilitation specialist to objective indicators of driving performance derived from the naturalistic data. Methods Drivers ≥70 years old are recruited from ophthalmology clinics and a previous population-based study of older drivers, with the goal of recruiting persons with wide ranging visual function. Target samples size is 195 drivers. At a baseline visit, the DAS is installed in the participant’s vehicle and a battery of health and functional assessments are administered to the driver including visual-sensory and visual-cognitive tests. The DAS remains installed in the vehicle for six months while the participant goes about his/her normal driving with no imposed study restrictions. After six months, the driver returns for DAS de-installation, repeat vision testing, and an on-road driving evaluation by a certified driving rehabilitation specialist (CDRS). The data streams recorded by the DAS are uploaded to the data coordinating center for analysis. Discussion The Alabama VIP Older Driver Study is the first naturalistic older driver study specifically focused on the enrollment of drivers with vision impairment in order to study the relationship between visual dysfunction and driver safety and performance.

Purpose To investigate the natural history of dot subretinal drusenoid deposits (SDD) in age-related macular degeneration, using high-resolution adaptive optics scanning laser ophthalmoscopy. Methods Six eyes of four patients with intermediate age-related macular degeneration were studied at baseline and 1 year later. Individual dot SDD within the central 30° retina were examined with adaptive optics scanning laser ophthalmoscopy and optical coherence tomography. Results A total of 269 solitary SDD were identified at baseline. Over 12.25 ± 1.18 months, all 35 Stage 1 SDD progressed to advanced stages. Eighteen (60%) Stage 2 lesions progressed to Stage 3 and 12 (40%) remained at Stage 2. Of 204 Stage 3 SDD, 12 (6.4%) disappeared and the rest remained. Twelve new SDD were identified, including 6 (50%) at Stage 1, 2 (16.7%) at Stage 2, and 4 (33.3%) at Stage 3. The mean percentage of the retina affected by dot SDD, measured by the adaptive optics scanning laser ophthalmoscopy, increased in 5/6 eyes (from 2.31% to 5.08% in the most changed eye) and decreased slightly in 1/6 eye (from 10.67% to 10.54%). Dynamism, the absolute value of the areas affected by new and regressed lesions, ranged from 0.7% to 9.3%. Conclusion Adaptive optics scanning laser ophthalmoscopy reveals that dot SDD, like drusen, are dynamic.

To compare the ability of several visual functional tests in terms of the strength of their associations with the earliest phases of age-related macular degeneration (AMD), which bears on their potential to serve as functional endpoints in evaluating treatments for early AMD and prevention strategies.Eyes from adults ≥60 years old were identified as being in normal macular health or in the earliest stages of AMD (steps 2, 3 or 4) through grading of color stereo-fundus photos by an experienced grader masked to all other study variables who used the 9-step Age-Related Eye Disease Study (AREDS) classification system for AMD severity. Visual function was assessed using the following tests: best-corrected visual acuity, low luminance visual acuity, spatial contrast sensitivity, macular cone-mediated light sensitivity and rod-mediated dark adaptation.A total of 1260 eyes were tested from 640 participants; 1007 eyes were in normal macular health (defined as step 1 in AREDS system) and 253 eyes had early AMD (defined as steps 2, 3 or 4). Adjusting for age and gender, early AMD eyes had two times the odds of having delayed rod-mediated dark adaptation than eyes in normal macular health (p = 0.0019). Visual acuity, low luminance acuity, spatial contrast sensitivity and macular light sensitivity did not differ between normal eyes and early AMD eyes.Eyes in the earliest phases of AMD were two times more likely to have delayed rod-mediated dark adaptation, as assessed by the rod-intercept, as compared to older eyes in normal macular health, whereas there was no difference in early AMD versus normal eyes in tests of visual acuity, low luminance acuity, macular light sensitivity and spatial contrast sensitivity.

PURPOSE: To evaluate the association between the binocular visual field defects in drivers with glaucoma and the risk of motor vehicle collision (MVC) involvement. METHODS: A retrospective cohort study was conducted on 438 drivers with glaucoma aged 55 years or older using data from 1994 through 2000. Demographic, clinical, and driving characteristics were obtained from chart abstractions and patient survey. Binocular field measures were generated by combining data from the monocular (central 24-degree radius) fields whereby the binocular field measure was defined as the more sensitive point at each monocular field location. Measures included threshold (TH), total deviation (TD), and pattern deviation (PD); severe impairment in these measures was defined as falling into the worst quartile. MVC data were obtained from police records. Rate ratios (RR) and 95% confidence intervals (CI) were calculated. RESULTS: Drivers with severely impaired PD measures were twice as likely to have an at-fault MVC compared with those not severely impaired (RR, 2.13; 95% CI, 1.21-3.75); those with severely impaired TH (RR, 1.49; 95% CI, 0.81-2.74) and TD (RR, 1.50; 95% CI, 0.82-2.74) also had an increased rate of at-fault MVCs, although these were not significant. When the binocular central visual field was stratified into 9 regions, drivers with impaired TH, TD, or PD had similarly elevated MVC rates in all regions compared with those not severely impaired, though not all reached statistical significance. CONCLUSIONS: On the basis of clinical measures of visual field routinely used in the management of glaucoma, drivers with glaucoma with severe PD field defects in the binocular field have a higher rate of at-fault MVC compared with those with less impaired or unimpaired binocular visual fields. Language: en

Purpose To examine the association between subretinal drusenoid deposits (SDDs) identified by multimodal retinal imaging and visual function in older eyes with normal macular health or in the earliest phases of age-related macular degeneration (AMD). Methods Age-related macular degeneration status for each eye was defined according to the Age-Related Eye Disease Study (AREDS) 9-step classification system (normal = Step 1, early AMD = Steps 2-4) based on color fundus photographs. Visual functions measured were best-corrected photopic visual acuity, contrast and light sensitivity, mesopic visual acuity, low-luminance deficit, and rod-mediated dark adaptation. Subretinal drusenoid deposits were identified through multimodal imaging (color fundus photographs, infrared reflectance and fundus autofluorescence images, and spectral domain optical coherence tomography). Results The sample included 1,202 eyes (958 eyes with normal health and 244 eyes with early AMD). In normal eyes, SDDs were not associated with any visual function evaluated. In eyes with early AMD, dark adaptation was markedly delayed in eyes with SDDs versus no SDD (a 4-minute delay on average), P = 0.0213. However, this association diminished after age adjustment, P = 0.2645. Other visual functions in early AMD eyes were not associated with SDDs. Conclusion In a study specifically focused on eyes in normal macular health and in the earliest phases of AMD, early AMD eyes with SDDs have slower dark adaptation, largely attributable to the older ages of eyes with SDD; they did not exhibit deficits in other visual functions. Subretinal drusenoid deposits in older eyes in normal macular health are not associated with any visual functions evaluated.

Motor vehicle collisions (MVCs) continue to place an increased burden on both individuals and health care systems. Self-reported and state-recorded police reports are the most common methods for MVC evaluation in epidemiologic studies, with varying degrees of agreement of information when compared in previous studies. The objective of the current study is to address the differences in MVC reporting and provide a more robust measure of the agreement between self-reported and state-recorded MVCs in a community dwelling population of older adults.A three-year prospective study was conducted in a population-based sample of 2000 licensed drivers aged 70 and older. At annual visits, participants were asked to self-report information on any MVC that occurred over the prior year where police were called to the scene. Information on police-reported MVCs was also ascertained from Alabama official state-recorded databases. The kappa coefficient was calculated to determine overall agreement between any self-reported and state-recorded crashes, as well as the raw number of crashes reported. In addition, agreement was stratified by demographics, health status, medication use, functional status (i.e. vision, cognition), and driving habits.1747 participants who completed three years of follow up were involved in 225 state-recorded MVCs and 208 self-reported MVCs yielding overall substantial agreement between any self-report and state-recorded MVC (kappa=0.64). Cumulative number of self-reported and state-recorded MVCs was also compared, with agreement slightly reduced (kappa=0.55). The clinical characteristic resulting in the greatest variation in agreement with drivers was impaired contrast sensitivity showing better agreement between self-reported and state-recorded MVCs (kappa=0.9) than those with non-impaired contrast sensitivity (kappa=0.6).Study results showed substantial agreement between self-reported and state-recorded MVCs for any MVC involvement among the study population. When examining the reporting of the total number of MVCs over the three year period, agreement was reduced to a moderate level. There was consistency in agreement across MVC risk factors except among individuals with contrast sensitivity. These findings have implications for the design and analytic planning of epidemiologic and clinical research focused on MVCs.

PURPOSE To determine if laminar depth (LD) and prelaminar tissue volume (PTV) are associated with age and race in healthy human eyes. METHODS Optic nerve head images from enhanced depth imaging spectral-domain optical coherence tomography of 166 normal eyes from 84 subjects of African descent (AD) and European descent (ED) were manually delineated to identify the principal surfaces: internal limiting membrane, Bruch's membrane (BM), anterior sclera (AS), and anterior surface of the lamina cribrosa. These four surfaces defined the LD and PTV using Bruch's membrane opening (BMO) and AS for reference structures. Generalized estimating equations were used to evaluate whether the effect of age on each outcome was differential by race. RESULTS When age was analyzed as a continuous variable, the interaction term between age and race was statistically significant for mean LDBMO (P = 0.015) and mean LDAS (P = 0.0062) after adjusting for axial length and BMO area. For every 1-year increase in age, the LDAS was greater on average by 1.78 μm in AD subjects and less by 1.71 μm in ED subjects. Mean PTV was lower in the older subjects (1248 × 10(6) μm(3) AD, 881 × 10(6) μm(3) ED) compared to the younger subjects (1316 × 10(6) μm(3) AD, 1102 × 10(6) μm(3) ED) in both groups. CONCLUSIONS With increasing age, the LD changes differently across racial groups in normal subjects. The LD in ED subjects showed a significantly decreasing slope suggesting that the lamina moves anteriorly with age in this group.

PURPOSE: We designed a visual field test focused on the field utilized while driving to examine associations between field impairment and motor vehicle collision involvement in 2,000 drivers ≥70 years old. METHODS: The "driving visual field test" involved measuring light sensitivity for 20 targets in each eye, extending 15° superiorly, 30° inferiorly, 60° temporally and 30° nasally. The target locations were selected on the basis that they fell within the field region utilized when viewing through the windshield of a vehicle or viewing the dashboard while driving. Monocular fields were combined into a binocular field based on the more sensitive point from each eye. Severe impairment in the overall field or a region was defined as average sensitivity in the lowest quartile of sensitivity. At-fault collision involvement for five years prior to enrollment was obtained from state records. Poisson regression was used to calculate crude and adjusted rate ratios examining the association between field impairment and at-fault collision involvement. RESULTS: Drivers with severe binocular field impairment in the overall driving visual field had a 40% increased rate of at-fault collision involvement (RR 1.40, 95%CI 1.07-1.83). Impairment in the lower and left fields was associated with elevated collision rates (RR 1.40 95%CI 1.07-1.82 and RR 1.49, 95%CI 1.15-1.92, respectively), whereas impairment in the upper and right field regions was not. CONCLUSIONS: Results suggest that older drivers with severe impairment in the lower or left region of the driving visual field are more likely to have a history of at-fault collision involvement. Language: en

Older adults who undergo cataract extraction have roughly half the rate of motor vehicle collision (MVC) involvement per mile driven compared to cataract patients who do not elect cataract surgery. Currently in the U.S., most insurers do not allow payment for cataract surgery based upon the findings of a vision exam unless accompanied by an individual’s complaint of visual difficulties that seriously interfere with driving or other daily activities and individuals themselves may be slow or reluctant to complain and seek relief. As a consequence, surgery tends to occur after significant vision problems have emerged. We hypothesize that a proactive policy encouraging cataract surgery earlier for a lesser level of complaint would significantly reduce MVCs among older drivers. We used a Monte Carlo model to simulate the MVC experience of the U.S. population from age 60 to 89 under alternative protocols for the timing of cataract surgery which we call “Current Practice” (CP) and “Earlier Surgery” (ES). Our base model finds, from a societal perspective with undiscounted 2010 dollars, that switching to ES from CP reduces by about 21% the average number of MVCs, fatalities, and MVC cost per person. The net effect on total cost – all MVC costs plus cataract surgery expenditures -- is a reduction of about 16%. Quality Adjusted Life Years would increase by about 5%. From the perspective of payers for healthcare, the switch would increase cataract surgery expenditure for ages 65+ by about 8% and for ages 60 to 64 by about 47% but these expenditures are substantially offset after age 65 by reductions in the medical and emergency services component of MVC cost. Similar results occur with discounting at 3% and with various sensitivity analyses. We conclude that a policy of ES would significantly reduce MVCs and their associated consequences.

Background Little is known about motor vehicle collision (MVC) risk in older drivers with age-related macular degeneration (AMD). The purpose of this study is to examine associations between MVC involvement and AMD presence and severity. Methods In a retrospective cohort study pooling the samples from four previous studies, we examined associations between MVC rate and older drivers with early, intermediate or advanced AMD as compared with those in normal eye health. MVC data were based on accident reports obtained from the state agency that compiles this information. Results MVC rate was highest among those in normal eye health and progressively declined among those with early and intermediate disease, and then increased for those with advanced AMD. However, only for drivers with intermediate AMD was the MVC rate significantly different (lower) as compared with those in normal eye health, regardless of whether the rate was defined in terms of person-years (RR 0.34, 95% CI 0.13 to 0.89) or person-miles (RR 0.35, 95% CI 0.13 to 0.91) of driving. Conclusions These results suggest that older drivers with intermediate AMD have a reduced risk of collision involvement. Further research should investigate whether self-regulatory driving practices by these drivers (avoiding challenging driving situations) underlies this reduced risk.

Purpose: To examine the relationship between vision impairment and driving exposure (amount of driving one does) in a population-based sample of older drivers and to examine to what extent cognitive status impacts this relationship. Methods: Enrollees consisted of a population-based sample of older adults from Alabama who were ≥70 years old, held a current driver's license, and had driven within the last 3 months. Three aspects of visual function were measured under binocular conditions - habitual distance visual acuity, contrast sensitivity and visual processing speed. General cognitive status was assessed with the mini-mental status examination. Driving exposure was estimated by the Driving Habits Questionnaire that asked about the number of miles, places, trips and days driven per week. Results: Drivers with impaired contrast sensitivity exhibited reduced annual mileage, and a decreased number of places and trips driven per week compared to those with normal contrast sensitivity, even after adjustment for other factors. Slowed visual processing speed was associated with reduced number of days driven per week after adjustment. Visual acuity deficit was not associated with changes in driving exposure. Cognitive status did not impact any of the associations between vision impairment and driving exposure. Conclusion: Older drivers with contrast sensitivity impairment exhibit reduced driving exposure in terms of number of trips and places they drive per week, as well as decreased annual mileage. These apparent self-regulatory practices should be viewed as adaptive because contrast sensitivity impairment elevates motor vehicle collision (MVC) risk and reduction in driving exposure can reduce MVC risk. Language: en

OBJECTIVES: To examine the association between visual and hearing impairment and motor vehicle collision (MVC) involvement in older drivers. DESIGN: Retrospective cohort study. SETTING: North central Alabama. PARTICIPANTS: Population-based sample of 2,000 licensed-drivers aged 70 and older. MEASUREMENTS: Visual acuity was measured using the Electronic Visual Acuity test. Contrast sensitivity was measured using the Pelli-Robson chart. Presence of subjective hearing loss and other health conditions were determined using a general health questionnaire. Information regarding MVCs for all participants spanning the 5 years before study enrollment was obtained from the Alabama Department of Public Safety. RESULTS: After adjustment for age, race, sex, number of miles driven, number of medical conditions, general cognitive status, and visual processing speed, older drivers with visual acuity and hearing impairment (rate ratio (RR) = 1.52, 95% confidence interval (CI) = 1.01-2.30), contrast sensitivity impairment alone (RR = 1.42, 95% CI = 1.00-2.02), and contrast sensitivity and hearing impairment (RR = 2.41, 95% CI = 1.62-3.57) had higher MVC rates than drivers with no visual or hearing impairments. Drivers with visual acuity loss alone or hearing loss alone did not have MVC rates that were significantly different from those of the no impairment group after adjustment for multiple variables. CONCLUSION: Older drivers with dual sensory impairment are at greater MVC risk than those with a visual acuity or hearing deficit alone. A combined screening approach of screening for hearing and visual impairment may be a useful tool to identify older drivers at risk of MVC involvement. Language: en

Objective: To examine rates of visual impairment of older adults in assisted living facilities (ALFs). Methods: Vision screening events were held at 12 ALFs in Jefferson County, Alabama, for residents above 60 years of age. Visual acuity, cognitive status, and presence of eye conditions were assessed. Results: A total of 144 residents were screened. Of these 67.8% failed distance screening, 70.9% failed near screening, and 89.3% failed contrast sensitivity screening. A total of 40.4% of residents had cognitive impairment and 89% had a least one diagnosed eye condition. Visual acuities did not differ significantly between cognitive status groups or with greater numbers of eye conditions. Discussion: This study is the first to provide information about vision impairment in the assisted living population. Of those screened, 70% had visual acuity worse than 20/40 for distance or near vision, and 90% had impaired contrast sensitivity. Cognitive impairment accounted for a small percentage of the variance in near vision and contrast sensitivity.

We examined the impact of an eye health education program for older African Americans on attitudes about eye care and utilization, using a randomized trial design in a community setting. Participants were older African Americans attending activities at senior centers. Ten centers were randomized to an eye health education (InCHARGE) or social-contact control presentation. InCHARGE addressed the importance of annual dilated comprehensive examination and strategies reducing barriers to care. The control presentation was on the importance of physical activity. Outcomes were attitudes about eye care 6 months post event through questionnaire and eye care utilization during 12 months post event through medical record abstraction. At baseline, more than 80% participants in both arms said transportation and finding, communicating, and trusting a doctor were not problematic and agreed that yearly care was important. One-fourth said eye examination cost was problematic; one-half said spectacle cost was problematic. There were no group differences 6 months post event. During the 12 months pre event, the dilated exam rate was similar in the groups (38.3% InCHARGE, 40.8% control) and unchanged during the 12 months post event. Results suggest fewer than half of older African Americans received annual dilated eye care. Group-administered eye health education did not increase this rate. Even before the program, they had positive attitudes about care, yet many cited examination and spectacle cost as problematic, which was not mitigated by health education. Evidence-based strategies in a community setting for increasing eye care utilization rate in older African Americans have yet to be identified. Policy changes may be more appropriate avenues for addressing cost. Trial Registration: NCT00591110, http://www.ClinicalTrials.gov

Importance The public health success of diabetic retinopathy (DR) screening programs depends on patients’ adherence to the timetable of follow-up eye care recommended by the screening program. African Americans are among those at highest risk for DR and have one of the lowest rates of eye care use. Objectives To assess the rate of adhering to recommended follow-up eye care in a DR screening program administered in a safety-net health care facility and to examine factors associated with follow-up eye care use. Design, Setting, and Participants Prospective follow-up study of persons with type 1 or type 2 diabetes. The setting was an internal medicine clinic of a publicly funded health system in Alabama, serving a population largely uninsured and African American, that had implemented a DR screening program using a nonmydriatic camera for ocular imaging and remote reading centers for evaluation of images. Patients with physician appointments between January 26 and July 24, 2012, were eligible for screening if they had a diagnosis of type 1 or type 2 diabetes and were 19 years or older. Data from the county health system’s administrative database were obtained from January 26, 2012 (date of first enrollee), through May 1, 2015, to establish participants’ eye care use in the ophthalmology clinic after screening. Main Outcomes and Measures Adherence to the recommended interval of follow-up eye appointments in the facility’s ophthalmology service as determined by administrative records, as well as factors associated with adherence. Results Diabetic retinopathy screening was completed in 949 adults with diabetes, of whom 84.5% (802 of 949) were African American, 64.5% (612 of 949) were women, and 71.7% (680 of 949) lacked health insurance. Participants ranged in age from 21 to 95 years, and their mean (SD) age was 53.9 (10.4) years. The mean (SD) age at diabetes diagnosis was 44.3 (12.5) years, and the mean (SD) duration of diabetes was 9.6 (9.4) years. Across interval recommendation types, 29.9% (284 of 949) adhered to obtaining comprehensive follow-up eye care within the recommended time frame. Two years after a participant’s screening date, 50.9% (483 of 949) had no record of having received eye care. Factors associated with adhering to interval appointments were having an advanced age (odds ratio, 1.02; 95% CI, 1.01-1.04) and knowing one’s glycated hemoglobin level (odds ratio, 2.00; 95% CI, 1.34-2.97). Agreeing to assistance in making a follow-up eye care appointment was associated with nonadherence (odds ratio, 0.67; 95% CI, 0.45-0.99). Conclusions and Relevance After a DR screening program in a public clinic largely serving an African American population, only one-third of participants adhered to interval recommendations for follow-up eye appointments, even though cost and accessibility were minimized as barriers to care. Our findings suggest that DR screening programs are not likely to meet their public health goals without incorporation of eye health education initiatives successfully promoting adherence to recommended comprehensive eye care for preventing vision loss.

To investigate the microscopic structure of outer retinal tubulation (ORT) and optical properties of cone photoreceptors in vivo, we studied ORT appearance by multimodal imaging, including spectral domain optical coherence tomography (SD-OCT) and adaptive optics scanning laser ophthalmoscopy. Four eyes of four subjects with advanced age-related macular degeneration underwent color fundus photography, infrared reflectance imaging, SD-OCT, and adaptive optics scanning laser ophthalmoscopy with a high-resolution research instrument. Outer retinal tubulation was identified in closely spaced (11 μm) SD-OCT volume scans. Outer retinal tubulation in cross-sectional and en face SD-OCT was a hyporeflective area representing a lumen surrounded by a hyperreflective border consisting of cone photoreceptor mitochondria and external limiting membrane, per previous histology. In contrast, ORT by adaptive optics scanning laser ophthalmoscopy was a hyporeflective structure of the same shape as in en face SD-OCT but lacking visualizable cone photoreceptors. Lack of ORT cone reflectivity by adaptive optics scanning laser ophthalmoscopy indicates that cones have lost their normal directionality and waveguiding property due to loss of outer segments and subsequent retinal remodeling. Reflective ORT cones by SD-OCT, in contrast, may depend partly on mitochondria as light scatterers within inner segments of these degenerating cells, a phenomenon enhanced by coherent imaging. Multimodal imaging of ORT provides insight into cone degeneration and reflectivity sources in optical coherence tomography.

Background Commonly used vision-targeted health-related quality of life questionnaires almost exclusively focus items on vision under daytime conditions. Older adults even when in good eye health frequently report experiencing vision problems at night and under low environmental light levels, and psychophysical studies also document these visibility problems. Here we compare the progression of self-reported low luminance visibility problems and self-reported visibility problems under daytime conditions in older adults. Methods Trained interviewers administered two questionnaires to older adults in normal eye health: the National Eye Institute Visual Function Questionnaire – 25 (NEI VFQ-25) where items are almost entirely focused on difficulties in daytime activities, and the Low Luminance Questionnaire (LLQ) where items are focused on difficulties seeing at night and under low luminance conditions. The following visual functions were also measured: visual acuity, low luminance visual acuity, low luminance deficit, contrast sensitivity, light sensitivity in the macula, and rod-mediated dark adaptation. The protocol was repeated 3 years later. Results Scores on the NEI VFQ-25 composite and its subscales were unchanged between baseline and 3-year follow-up, whereas scores on the LLQ composite and 5 of 6 subscales significantly decreased (corresponding to less functionality) at the 3-year follow-up. Participants were more likely to display a ≥ 5 point decrease on the LLQ composite than on the NEI VFQ-25 over 3 years. Visual functional tests were largely unrelated to changes in NEI VFQ-25 and LLQ scores from baseline to follow-up. Conclusions Older adults’ vision-targeted quality of life as measured by questionnaire is more likely to exhibit a practically significant decrease over 3 years using a questionnaire that focused on low luminance activities (LLQ) than one focused on daytime activities (NEI VFQ-25). That the results of visual functional testing did not correspond to older adults’ decline in self-reported problems in low luminance activities emphasizes the importance of questionnaires in understanding visual difficulties from the patients’ own perspective.

PURPOSE To compare the prevalence of attention deficit/hyperactivity disorder (ADHD) in children with normal vision and with vision problems not correctable with glasses or contact lenses (vision problems) as determined by parent report in a nationwide telephone survey. METHODS This cross-sectional study included 75,171 children without intellectual impairment aged 4 to 17 years participating in the 2011 to 2012 National Survey of Children's Health, conducted by the U.S. Centers for Disease Control and Prevention. Demographic information and information regarding vision and ADHD status were obtained by parent interview. Questions asked whether they had ever been told by a doctor or health care provider that the child had a vision problem not correctable with glasses or contact lenses, ADHD, intellectual impairment, or one of 13 other common chronic conditions of childhood. A follow-up question asked about condition severity. The main outcome measure was current ADHD. RESULTS The prevalence of current ADHD was greater (p < 0.0001) among children with vision problems (15.6%) compared with those with normal vision (8.3%). The odds of ADHD compared with those of children with normal vision were greatest for those with moderate vision problems (odds ratio [OR], 2.6; 95% confidence interval [95% CI], 1.7 to 4.4) and mild vision problems (OR, 1.8; 95% CI, 1.1 to 2.9). Children with severe vision problems had similar odds of ADHD to those of children with normal vision perhaps because of the small numbers in this group (OR, 1.6; 95% CI, 0.8 to 3.1). In multivariable analysis adjusting for confounding variables, vision problems remained independently associated with current ADHD (OR, 1.8; 95% CI, 1.2 to 2.7). CONCLUSIONS In this large nationally representative sample, the prevalence of ADHD was greater among children with vision problems not correctable with glasses or contacts. The association between vision problems and ADHD remains even after adjusting for other factors known to be associated with ADHD.

Purpose To test whether increased light transmission (hypertransmission) through subretinal drusenoid deposits (SDD) into the choroid in age-related macular degeneration (AMD) represented retinal pigment epithelium (RPE) degeneration. Design Cross-sectional study. Methods Nineteen eyes of 12 patients with early- to intermediate-stage AMD and 18 eyes of 12 normal subjects were evaluated with color fundus photography, optical coherence tomography (OCT), and high-resolution adaptive optics scanning laser ophthalmoscopy (AOSLO) at baseline and 24 months later. SDD were classified using an OCT-based 3-stage grading system. Hypertransmission beneath SDD into the choroid was examined in OCT. SDD microstructure was assessed with AOSLO. To characterize the hypertransmission-associated chorioretinal degeneration, choroidal thickness and photoreceptor length were measured in OCT at 1 mm and 2 mm superior, inferior, temporal, and nasal to the foveal center. Results OCT disclosed hypertransmission beneath stage 3 SDD in 8 eyes. These lesions showed a distinctive regressing structure in AOSLO, compared with stage 3 lesions without hypertransmission. The phenomenon persisted at follow-up, and new hypertransmission developed as SDD advanced. In eyes with hypertransmission, choroids were thinner than those of normal eyes at all sites (by 44%–56%, P ≤ .0028) and those of eyes with SDD but without hypertransmission at superior and temporal sites (by 31%–46%, P ≤ .039). Photoreceptors were significantly shorter than those in normal eyes (by 6%–26%, P ≤ .0379). Conclusions Hypertransmission into the choroid, accompanied with SDD regression and thinning of choroid and photoreceptor layers, indicates RPE degeneration associated with advanced stages in the SDD life cycle.