Initial experience in self-monitoring of intraocular pressure.

Background/aims: Diurnal variation in intraocular pressure (IOP) is a routine assessment in glaucoma management. Providing patients the opportunity to perform self-tonometry might empower them and free hospital resource. We previously demonstrated that 74% of patients can use the Icare® HOME tonometer. This study further explores Icare® HOME patient self-monitoring. Methods: Patients were trained by standard protocol to use the Icare® HOME rebound tonometer. Patient self-tonometry was compared to Goldmann applanation tonometry (GAT) over one clinical day. Following this, each patient was instructed to undertake further data collection that evening and over the subsequent two days. Results: Eighteen patients (35 eyes) participated. Good agreement was demonstrated between GAT and Icare® HOME for IOPs up to 15 mm Hg. Above this IOP the Icare® tended to over-read, largely explained by 2 patients with corneal thickness >600 um. The mean peak IOP during ‘clinic hours’ phasing was 16.7 mm Hg and 18.5 mm Hg (p = 0.24) over three days. An average range of 5.0, 7.0 and 9.8 mm Hg was shown during single day clinic, single day home and three day home phasing respectively (p =<0.001). The range of IOP was lower in eyes with prior trabeculectomy (6.1 mm Hg vs 12.2 mm Hg). All patients undertook one reading in the early morning at home with an average of 4.8 readings during, and 3.1 readings after office hours. Conclusions: This small study shows that self-tonometry is feasible. The findings from home phasing demonstrated higher peak and trough IOPs, providing additional clinical information. Home phasing is a viable alternative. The cost-effectiveness of this approach has yet to be addressed

Controversies in the use of nutritional supplements in ophthalmology

Nutritional supplements are widely taken by the general population and several of these products are marketed specifically to improve eye health. The aim of this review is to summarise the evidence for the benefit of supplementation with antioxidant vitamins and other micronutrients for three of the most common eye diseases of the elderly: age-related macular degeneration (AMD), cataract and dry eye syndrome (DES). Although the potential importance of diet and nutrition in these conditions is strongly supported by data from observational studies, evidence from randomised controlled trials (RCTs) on the benefit of nutritional supplementation is generally lacking. However, there is high quality evidence to support the use of an Age-Related Eye-Disease Study (AREDS) supplement containing antioxidants ( -carotene, vitamin C and vitamin E) and zinc to slow progression in those at moderate to high risk of developing advanced AMD. Recent data from the AREDS2 trial provided data to suggest that -carotene could be replaced with lutein and zeaxanthin on the based on improved safety without compromising efficacy. Although there is currently insufficient evidence to recommend the routine use of any of the commercially available supplements in cataract and DES, given the public health importance of these conditions further research into the benefit of dietary modification or nutritional supplementation should be a priority

Antioxidant vitamin and mineral supplements for preventing age-related macular degeneration

Background: There is inconclusive evidence from observational studies to suggest that people who eat a diet rich in antioxidant vitamins (carotenoids, vitamins C, and E) or minerals (selenium and zinc) may be less likely to develop age-related macular degeneration (AMD). Objectives: To determine whether or not taking antioxidant vitamin or mineral supplements, or both, prevent the development of AMD. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 2), MEDLINE Ovid (1946 to 29 March 2017), Embase Ovid (1947 to 29 March 2017), AMED (Allied and Complementary Medicine Database) (1985 to 29 March 2017), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/); searched 29 March 2017, the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 29 March 2017, ClinicalTrials.gov (www.clinicaltrials.gov); searched 29 March 2017 and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 29 March 2017. We did not use any date or language restrictions in the electronic searches for trials. Selection criteria: We included all randomised controlled trials (RCTs) comparing an antioxidant vitamin or mineral supplement (alone or in combination) to control. Data collection and analysis: Both review authors independently assessed risk of bias in the included studies and extracted data. One author entered data into RevMan 5; the other author checked the data entry. We pooled data using a fixed-effect model. We graded the certainty of the evidence using GRADE. Main results: We included a total of five RCTs in this review with data available for 76,756 people. The trials were conducted in Australia, Finland, and the USA, and investigated vitamin C, vitamin E, beta-carotene, and multivitamin supplements. All trials were judged to be at low risk of bias. Four studies reported the comparison of vitamin E with placebo. Average treatment and follow-up duration ranged from 4 to 10 years. Data were available for a total of 55,614 participants. There was evidence that vitamin E supplements do not prevent the development of any AMD (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.90 to 1.06; high-certainty evidence), and may slightly increase the risk of late AMD (RR 1.22, 95% CI 0.89 to 1.67; moderate-certainty evidence) compared with placebo. Only one study (941 participants) reported data separately for neovascular AMD and geographic atrophy. There were 10 cases of neovascular AMD (RR 3.62, 95% CI 0.77 to 16.95; very low-certainty evidence), and four cases of geographic atrophy (RR 2.71, 95% CI 0.28 to 26.0; very low-certainty evidence). Two trials reported similar numbers of adverse events in the vitamin E and placebo groups. Another trial reported excess of haemorrhagic strokes in the vitamin E group (39 versus 23 events, hazard ratio 1.74, 95% CI 1.04 to 2.91, low-certainty evidence). Two studies reported the comparison of beta-carotene with placebo. These studies took place in Finland and the USA. Both trials enrolled men only. Average treatment and follow-up duration was 6 years and 12 years. Data were available for a total of 22,083 participants. There was evidence that beta-carotene supplements did not prevent any AMD (RR 1.00, 95% CI 0.88 to 1.14; high-certainty evidence) nor have an important effect on late AMD (RR 0.90, 95% CI 0.65 to 1.24; moderate-certainty evidence). Only one study (941 participants) reported data separately for neovascular AMD and geographic atrophy. There were 10 cases of neovascular AMD (RR 0.61, 95% CI 0.17 to 2.15; very low-certainty evidence) and 4 cases of geographic atrophy (RR 0.31 95% CI 0.03 to 2.93; very low-certainty evidence). Beta-carotene was associated with increased risk of lung cancer in people who smoked. One study reported the comparison of vitamin C with placebo, and multivitamin (Centrum Silver) versus placebo. This was a study in men in the USA with average treatment duration and follow-up of 8 years for vitamin C and 11 years for multivitamin. Data were available for a total of 14,236 participants. AMD was assessed by self-report followed by medical record review. There was evidence that vitamin C supplementation did not prevent any AMD (RR 0.96, 95% CI 0.79 to 1.18; high-certainty evidence) or late AMD (RR 0.94, 0.61 to 1.46; moderate-certainty evidence). There was a slight increased risk of any AMD (RR 1.21, 95% CI 1.02 to 1.43; moderate-certainty evidence) and late AMD (RR 1.22, 95% CI 0.88 to 1.69; moderate-certainty evidence) in the multivitamin group. Neovascular AMD and geographic atrophy were not reported separately. Adverse effects were not reported but there was possible increased risk of skin rashes in the multivitamin group. Adverse effects were not consistently reported in these eye studies, but there is evidence from other large studies that beta-carotene increases the risk of lung cancer in people who smoke or who have been exposed to asbestos. None of the studies reported quality of life or resource use and costs. Authors' conclusions: Taking vitamin E or beta-carotene supplements will not prevent or delay the onset of AMD. The same probably applies to vitamin C and the multivitamin (Centrum Silver) investigated in the one trial reported to date. There is no evidence with respect to other antioxidant supplements, such as lutein and zeaxanthin. Although generally regarded as safe, vitamin supplements may have harmful effects, and clear evidence of benefit is needed before they can be recommended. People with AMD should see the related Cochrane Review on antioxidant vitamin and mineral supplements for slowing the progression of AMD, written by the same review team

Development and validation of a new glaucoma screening test using temporally modulated flicker

Purpose Describing the psychometric characteristics and diagnostic accuracy of the Accelerator 4‐Alternative Forced‐Choice Flicker Test prototype (A4FTp) for detecting chronic open angle glaucoma (COAG). Methods A4FTp measures temporally‐modulated flicker thresholds in regions of the visual field with high susceptibility to glaucomatous loss. We initially evaluated its psychometric properties on 20 normals (aged 33.8 ± 8.5 years) who were tested multiple times over a period of 3 months. All subjects underwent four repetitions for shorter (T8) and longer (T12) staircase termination criteria, to determine the most suitable threshold criterion. Four randomly selected subjects underwent a total of 10 repetitions to study test‐retest repeatability and learning effects. To determine its diagnostic accuracy, one eye of 40 participants with COAG and 38 normal controls were tested with the A4FTp in comparison with the Frequency Doubling Technology (FDT; C20‐5 programme) and iVue Spectral Domain Optical Coherence Tomography (SD‐OCT). Tests were conducted in a random order with results masked to the clinician conducting the reference ophthalmic examination. The accuracy of each test was determined by analysis of the area under the receiver operator characteristic curve (AUROC). Results A4FTp flicker thresholds were stable, with standard deviations of only 0.52 decilog (dL) for T8, increasing to 1.32 dL for T12, and no significant flicker sensitivity threshold improvement over the 10 repeat runs. T8 was superior to T12 on several other measures, so it was used for the remaining comparisons. In terms of diagnostic accuracy, the mean AUROC for the three tests were A4FTp [T8 criterion; 0.82, 95% confidence interval (0.73–0.92)]; SD‐OCT [any RNFL parameter p < 1% level; 0.90 (0.83–0.97)]; and FDT [one or more locations missed at p < 5% level; 0.91 (0.82–0.96)]. There was no statistical difference in AUROC between A4FTp and SD‐OCT (p = 0.18) or FDT (p = 0.12). The A4FTp test duration averaged just over 2 min per eye, taking approximately one‐third of the time for completion of the HFA SITA 24‐2 algorithm (conducted as part of the reference examination) and twice the time for the suprathreshold FDT. Conclusion Test accuracy for the A4FTp was comparable to those of the FDT and SD‐OCT for the detection of COAG. Time taken to complete the A4FTp was relatively short and initial results are promising. With further refinement, the A4FTp could have a future role in glaucoma detection

Blue-light filtering spectacle lenses for visual performance, sleep, and macular health in adults

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess whether blue-light filtering spectacle lenses impart effects on visual function, provide protection to the macula, or both. We will also examine potential effects on the sleep-wake cycle

Nutrition and Eye Health

Diet is a key lifestyle factor that can have long-term effects on ocular health [...]