Effectiveness of Community versus Hospital Eye Service follow-up for patients with neovascular age-related macular degeneration with quiescent disease (ECHoES): a virtual non-inferiority trial

Objectives: To compare the ability of ophthalmologists versus optometrists to correctly classify retinal lesions due to neovascular age-related macular degeneration (nAMD). Design: Randomised balanced incomplete block trial. Optometrists in the community and ophthalmologists in the Hospital Eye Service classified lesions from vignettes comprising clinical information, colour fundus photographs and optical coherence tomographic images. Participants' classifications were validated against experts' classifications (reference standard). Setting: Internet-based application. Participants: Ophthalmologists with experience in the age-related macular degeneration service; fully qualified optometrists not participating in nAMD shared care. Interventions: The trial emulated a conventional trial comparing optometrists' and ophthalmologists' decision-making, but vignettes, not patients, were assessed. Therefore, there were no interventions and the trial was virtual. Participants received training before assessing vignettes. Main outcome measures: Primary outcome- correct classification of the activity status of a lesion based on a vignette, compared with a reference standard. Secondary outcomes-potentially sight-threatening errors, judgements about specific lesion components and participants' confidence in their decisions. Results: In total, 155 participants registered for the trial; 96 (48 in each group) completed all assessments and formed the analysis population. Optometrists and ophthalmologists achieved 1702/2016 (84.4%) and 1722/2016 (85.4%) correct classifications, respectively (OR 0.91, 95% CI 0.66 to 1.25; p=0.543). Optometrists' decision-making was non-inferior to ophthalmologists' with respect to the prespecified limit of 10% absolute difference (0.298 on the odds scale). Optometrists and ophthalmologists made similar numbers of sight-threatening errors (57/994 (5.7%) vs 62/994 (6.2%), OR 0.93, 95% CI 0.55 to 1.57; p=0.789). Ophthalmologists assessed lesion components as present less often than optometrists and were more confident about their classifications than optometrists. Conclusions: Optometrists' ability to make nAMD retreatment decisions from vignettes is not inferior to ophthalmologists' ability. Shared care with optometrists monitoring quiescent nAMD lesions has the potential to reduce workload in hospitals

The Effectiveness, cost-effectiveness and acceptability of Community versus Hospital Eye Service follow-up for patients with neovascular age-related macular degeneration with quiescent disease (ECHoES): a virtual randomised balanced incomplete block trial

Background Patients with neovascular age-related macular degeneration (nAMD) usually attend regular reviews, even when the disease is quiescent. Reviews are burdensome to health services, patients and carers. Objectives To compare the proportion of correct lesion classifications made by community-based optometrists and ophthalmologists from vignettes of patients; to estimate the cost-effectiveness of community follow-up by optometrists compared with follow-up by ophthalmologists in the Hospital Eye Service (HES); to ascertain views of patients, their representatives, optometrists, ophthalmologists and clinical commissioners on the proposed shared care model. Design Community-based optometrists and ophthalmologists in the HES classified lesions from vignettes comprising clinical information, colour fundus photographs and optical coherence tomography images. Participants’ classifications were validated against experts’ classifications (reference standard). Setting Internet-based application. Participants Ophthalmologists had to have≥3 years post-registration experience in ophthalmology, have passed part 1 of the Royal College of Ophthalmologists, Diploma in Ophthalmology or equivalent examination, and have experience in the age-related macular degeneration service. Optometrists had to be fully qualified, be registered with the General Optical Council for≥3 years and not be participating in nAMD shared care. Interventions The trial sought to emulate a conventional trial in comparing optometrists’ and ophthalmologists’ decision-making, but vignettes, not patients, were assessed; therefore, there were no interventions. Participants received training prior to assessing vignettes Main Outcome Measures Primary outcome–correct classification of the activity status of a lesion based on a vignette, compared with a reference standard. Secondary outcomes–frequencies of potentially sight-threatening errors, participants’ judgements about specific lesion components, participant-rated confidence in their decisions and cost-effectiveness of follow-up by community-based optometrists compared with HES ophthalmologists. Results In total, 155 participants registered for the trial; 96 (48 in each professional group) completed training and main assessments and formed the analysis population. Optometrists and ophthalmologists achieved 1702 out of 2016 (84.4%) and 1722 out of 2016 (85.4%) correct classifications, respectively [odds ratio (OR) 0.91, 95% confidence interval (CI) 0.66 to 1.25; p=0.543]. Optometrists’ decisionmaking was non-inferior to ophthalmologists’ with respect to the pre-specified limit of 10% absolute difference (0.298 on the odds scale). Frequencies of sight-threatening errors were similar for optometrists and ophthalmologists [57/994 (5.7%) vs. 62/994 (6.2%), OR 0.93, 95% CI 0.55 to 1.57;p=0.789]. Ophthalmologists assessed lesion components as present less often than optometrists and were more confident about their lesion classifications than optometrists. The mean care-pathway cost for assessment was very similar by group, namely £397.33 for ophthalmologists and £410.78 for optometrists. The optometrist-led monitoring reviews were slightly more costly and less effective than ophthalmologist-led reviews, although the differences were extremely small. There was consensus that optometrist-led monitoring has the potential to reduce clinical workload and be more patient-centred. However, potential barriers are ophthalmologists’ perceptions of optometrists’ competence, the need for clinical training, the ability of the professions to work collaboratively and the financial feasibility of shared care for Clinical Commissioning Groups Conclusions The ability of optometrists to make nAMD retreatment decisions from vignettes is non-inferior to that of ophthalmologists. Various barriers to implementing shared cared for nAMD were identified. Future Work Recommendations The Effectiveness, cost-effectiveness and acceptability of Community versus Hospital Eye Service follow-up for patients with neovascular age-related macular degeneration with quiescent disease (ECHoES) study web application was robust and could be used for future training or research. The benefit of reducing HES workload was not considered in the economic evaluation. A framework of programme budgeting and marginal analysis could explicitly explore the resource implications of shifting resources within a given health service area, as the benefit of reducing HES workload was not considered in the economic evaluation. Future qualitative research could investigate professional differences of opinion that were identified in multidisciplinary focus groups.</p

Prevalence of Age-Related Macular Degeneration in Europe: The Past and the Future

Purpose Age-related macular degeneration (AMD) is a frequent, complex disorder in elderly of European ancestry. Risk profiles and treatment options have changed considerably over the years, which may have affected disease prevalence and outcome. We determined the prevalence of early and late AMD in Europe from 1990 to 2013 using the European Eye Epidemiology (E3) consortium, and made projections for the future. Design Meta-analysis of prevalence data. Participants A total of 42 080 individuals 40 years of age and older participating in 14 population-based cohorts from 10 countries in Europe. Methods AMD was diagnosed based on fundus photographs using the Rotterdam Classification. Prevalence of early and late AMD was calculated using random-effects meta-analysis stratified for age, birth cohort, gender, geographic region, and time period of the study. Best-corrected visual acuity (BCVA) was compared between late AMD subtypes; geographic atrophy (GA) and choroidal neovascularization (CNV). Main Outcome Measures Prevalence of early and late AMD, BCVA, and number of AMD cases. Results Prevalence of early AMD increased from 3.5% (95% confidence interval [CI] 2.1%–5.0%) in those aged 55–59 years to 17.6% (95%

Grading of age-related maculopathy:slit-lamp biomicroscopy versus an accredited grading center

PURPOSE: To compare clinical age-related maculopathy (ARM) grading using slit-lamp biomicroscopy (SLB) versus photographic grading of stereoscopically captured fundus photographs (FP) using a high-resolution fundus camera. METHODS: A subset (129) of participants in the Carotenoids in ARM study were clinically graded for ARM signs and the corresponding FPs were graded in an accredited reading center. RESULTS: Drusen were said to be present in 192 (94.5%) eyes graded by FP, and in 165 (82.5%) eyes examined by SLB (agreement = 84%, k = 0.23). A good and modest degree of agreement was observed between SLB and FP for quantification of total drusen number (agreement = 81%, k = 0.33) and for classification of drusen subtypes (agreement = 60%, k = 0.33), respectively. Localization of drusen to either the inner zone or the outer zone was comparable for both techniques of ARM grading (inner zone: agreement = 89%; outer zone: agreement = 88%, k = 0.39). Agreement between SLB and FP was 76% (k = 0.46) for identification of any pigment abnormality; however, agreement was less for hypo-pigmentation abnormalities (agreement = 64%, k = 0.21). CONCLUSIONS: From the statistical perspective, SLB grading of ARM is generally comparable with findings from standardized grading of FP. However, the lower levels of agreement for classification of drusen subtypes and detection of hypo-pigmentation suggest these features may go unrecorded in a study which relies on SLB for grading ARM

Quantitative fluorescein angiographic analysis of choroidal neovascular membranes: validation and correlation with visual function. I Invest Ophthalmol Vis Sci 48

PURPOSE. To compare computerized analysis with traditional grading methods in the analysis of fluorescein angiograms from patients with choroidal neovascularization (CNV) due to agerelated macular degeneration (AMD) and to examine the clinical relevance of parameters generated by computerized analysis by testing their relationships with clinical measures of vision. METHODS. Custom quantitative fluorescein analysis (QFA) software was used to analyze 62 angiograms from patients with CNV for whom distance visual acuity (DVA) data were available. On applying QFA, we obtained three mathematical parameters for each lesion component: pixel area (PA), integrated intensity (II), and positive fluorescence (PF). Quotients (Q) were derived for the latter two parameters by correcting against background (b) T he scientific literature contains many reports on the interpretation of fundus fluorescein angiograms to diagnose and classify choroidal neovascularization (CNV), a devastating complication of age-related macular degeneration (AMD). Clinically, the presence of CNV is diagnosed when an exudative lesion is seen in the macular region of the posterior fundus of the eye. 1 There is much interest in the quantification of the angiographic features of CNV, as these parameters are used as markers for monitoring a therapeutic response. To date, the techniques used in angiographic analysis are based on subjective interpretation by experienced clinicians or trained graders of the patterns of fluorescence depicted in the angiographic sequences. 2-4 Normal and abnormal patterns of fluorescence have been described, and the latter are considered to represent pathologic processes in specific tissues or compartments within the exudative lesion. Notably, abnormal spatial localization of hyperfluorescence and temporal alterations in patterns of hyper-and hypofluorescence are used to describe the presence of leaking new choroidal vessels. 2,5 Quantification of the many components of an exudative lesion was usually accomplished by analyzing single angiographic frames with graded categorical methods (MPS circles) or through the application of image analysis to angiographic images. The objective of the present study was to compare the grading output from newly developed custom software (computerized analysis) with that of traditional grading and to assess the clinical relevance of the former by examining their relationships with measures of vision