Ophthalmology (Eye & Ear Hospital) - Research Publications
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ItemDiet soft drink is associated with increased odds of proliferative diabetic retinopathy(WILEY, 2018-09)IMPORTANCE: While consumption of soft drink may increase the risk of cardiovascular disease, the relationship between soft drink consumption and diabetes complications is unknown. BACKGROUND: To explore the association between regular and diet soft drink consumption, and diabetic retinopathy (DR) and diabetic macular oedema (DME). DESIGN: Clinical, cross-sectional study. PARTICIPANTS: Adult patients with diabetes recruited from a tertiary eye hospital (Melbourne, Australia) answered a Food Frequency Questionnaire. METHODS: None, moderate and high soft drink consumption was defined as <1, 1-4 and >4 cans/bottles (375 mL) per week, respectively. Due to missing data, data were imputed using the multiple imputation chained equation procedure. Multivariable logistic regression models determined the associations between soft drink consumption, and presence and severity of DR/DME. MAIN OUTCOME MEASURES: Presence and severity of DR/DME. RESULTS: Of the 609 participants (mean age ± standard deviation: 64.6 ± 11.6 years; males = 210), 285 (46.8%) and 190 (31.2%) consumed diet and regular soft drink, respectively. A total of 230 (37.8%), 36 (5.9%), 154 (25.3%), 28 (4.6%) and 146 (24.0%) had no DR, mild non-proliferative DR (NPDR), moderate NPDR, severe NPDR and proliferative DR (PDR), respectively. High diet soft drink consumption was independently associated with increased likelihood of having PDR (odds ratio = 2.51, 95% confidence interval = 1.05-5.98), compared to no consumption. In contrast, regular soft drink was not associated with DR or DME. CONCLUSIONS AND RELEVANCE: Consuming >4 cans (1.5 L)/week of diet soft drink is associated with a more than twofold risk of having PDR in patients with diabetes. Longitudinal studies are needed to further elucidate the association and its underpinning mechanisms.
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ItemCombined poor diabetes control indicators are associated with higher risks of diabetic retinopathy and macular edema than poor glycemic control alone(PUBLIC LIBRARY SCIENCE, 2017-06-29)PURPOSE: To examine the association of individual and combined indicators of diabetes control with diabetic retinopathy and diabetic macular edema. MATERIALS AND METHODS: In this clinical, cross-sectional study, 613 adults with type 2 diabetes (372 any diabetic retinopathy; 183 any diabetic macular edema) were examined. Diabetic retinopathy was assessed from fundus photographs; diabetic macular edema from Ocular Coherence Tomography scans; and HbA1c and serum lipid values from fasting blood samples. Poor glucose control was defined as HbA1c≥7%; poor blood pressure control as SBP≥130/DBP≥80; and poor lipid control as total cholesterol:HDL ratio≥4.0. The association of poor glucose control, poor blood pressure control and poor lipid control alone and in combination (poor glucose & blood pressure control; poor glucose & lipid control; poor blood pressure & lipid control; and poor glucose, blood pressure & lipid control) with diabetic retinopathy/diabetic macular edema was examined using multiple logistic regression models. RESULTS: Patients' mean±standard deviation age was 64.9±11.6 years (57% male). In adjusted models, compared to those with good control of all indicators (n = 99, 18.3%), the odds ratio (95% Confidence Interval) of having any diabetic retinopathy was 2.44 (1.34-4.46), 3.75 (1.75-8.07), 4.64 (2.13-10.12) and 2.28 (1.01-5.16) for poor glucose control only; poor glucose & blood pressure control; poor glucose & lipid control; and poor glucose, blood pressure & lipid control, respectively. Correspondingly for diabetic macular edema, they were 3.19 (1.55-6.59); 3.60 (1.58-8.22); 2.76 (1.18-6.44); and 3.01 (1.18-7.67), respectively. Odds were not significantly increased for other indicators. DISCUSSION: Compared to individual indicators of poor diabetes control, risk of diabetic retinopathy and diabetic macular edema increased three to fourfold with a combination of these indicators. Targeting combined diabetes control indicators is important to reduce risk of diabetic retinopathy/diabetic macular edema.
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ItemPrevalence, Risk Factors, and Impact of Undiagnosed Visually Significant Cataract: The Singapore Epidemiology of Eye Diseases Study(PUBLIC LIBRARY SCIENCE, 2017-01-27)OBJECTIVE: To determine the prevalence, risk factors, and impact of undiagnosed visually significant cataract in an Asian population. METHODS: The Singapore Epidemiology of Eye Diseases is a population-based study where 8,697 adults of Malay, Indian, and Chinese ethnicities aged > 40 years were invited for an eye examination, including lens photograph, to establish cataract diagnosis. Visually significant cataract was defined by Wisconsin Cataract Grading System and a best-corrected visual acuity <20/40 with cataract as the primary cause of vision impairment. Participants were deemed 'undiagnosed' if they had visually significant cataract and reported no prior physician diagnosis of cataract. Visual functioning (VF) was assessed with the VF-11 questionnaire validated using Rasch analysis. RESULTS: Among the 925 participants with visually significant cataract, 636 (68.8%) were unaware of their cataract status. Age-standardized prevalence varied according to ethnicity, with Malays having higher rates than Chinese and Indians. Factors independently associated with having undiagnosed visually significant cataract were: Malay ethnicity, lower educational attainment, in employment, and without a history of diabetes (all P<0.05). In those with undiagnosed visually significant cataract, half had bilateral visual impairment, which was significantly associated with 24.8% poorer visual functioning compared to those with unilateral visual impairment (P<0.001). CONCLUSIONS: Two-thirds of Singaporean adults with visually significant cataract were previously undiagnosed. Half of these cases had bilateral visual impairment and substantially reduced quality of life. Public health strategies targeting elderly patients, such as regular screening for visual impairment and timely referral to ophthalmologists in order to prevent progression to bilateral visual impairment when visual function is compromised are warranted.
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ItemComputerized Adaptive Tests: Efficient and Precise Assessment of the Patient-Centered Impact of Diabetic Retinopathy(ASSOC RESEARCH VISION OPHTHALMOLOGY INC, 2020-06)PURPOSE: Evaluate efficiency, precision, and validity of RetCAT, which comprises ten diabetic retinopathy (DR) quality of life (QoL) computerized adaptive tests (CATs). METHODS: In this cross-sectional clinical study, 183 English and/or Mandarin-speaking participants with DR (mean age ± standard deviation [SD] 56.4 ± 11.9 years; 38% proliferative DR [worse eye]) were recruited from retinal clinics in Singapore. Participants answered the RetCAT tests (Symptoms, Activity Limitation, Mobility, Emotional, Health Concerns, Social, Convenience, Economic, Driving, and Lighting), which were capped at seven items each, and other questionnaires, and underwent eye tests. Our primary evaluation focused on RetCAT efficiency (i.e. standard error of measurement [SEM] ± SD achieved and time needed to complete each CAT). Secondary evaluations included an assessment of RetCAT's test precision and validity. RESULTS: Mean SEM across all RetCAT tests was 0.351, ranging from 0.272 ± 0.130 for Economic to 0.484 ± 0.130 for Emotional. Four tests (Mobility, Social, Convenience, and Driving) had a high level of measurement error. The median time to take each RetCAT test was 1.79 minutes, ranging from 1.12 (IQR [interquartile range] 1.63) for Driving to 3.28 (IQR 2.52) for Activity Limitation. Test precision was highest for participants at the most impaired end of the spectrum. Most RetCAT tests displayed expected correlations with other scales (convergent/divergent validity) and were sensitive to DR and/or vision impairment severity levels (criterion validity). CONCLUSIONS: RetCAT can provide efficient, precise, and valid measurement of DR-related QoL impact. Future application of RetCAT will employ a stopping rule based on SE rather than number of items to ensure that all tests can detect meaningful differences in person abilities. Responsiveness of RetCAT to treatment interventions must also be determined. TRANSLATIONAL RELEVANCE: RetCAT may be useful for measuring the patient-centered impact of DR severity and disease progression and evaluating the effectiveness of new therapies.
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ItemEvaluation of item candidates for a diabetic retinopathy quality of life item bank(SPRINGER, 2013-09)PURPOSE: We are developing an item bank assessing the impact of diabetic retinopathy (DR) on quality of life (QoL) using a rigorous multi-staged process combining qualitative and quantitative methods. We describe here the first two qualitative phases: content development and item evaluation. METHODS: After a comprehensive literature review, items were generated from four sources: (1) 34 previously validated patient-reported outcome measures; (2) five published qualitative articles; (3) eight focus groups and 18 semi-structured interviews with 57 DR patients; and (4) seven semi-structured interviews with diabetes or ophthalmic experts. Items were then evaluated during 3 stages, namely binning (grouping) and winnowing (reduction) based on key criteria and panel consensus; development of item stems and response options; and pre-testing of items via cognitive interviews with patients. RESULTS: The content development phase yielded 1,165 unique items across 7 QoL domains. After 3 sessions of binning and winnowing, items were reduced to a minimally representative set (n = 312) across 9 domains of QoL: visual symptoms; ocular surface symptoms; activity limitation; mobility; emotional; health concerns; social; convenience; and economic. After 8 cognitive interviews, 42 items were amended resulting in a final set of 314 items. CONCLUSIONS: We have employed a systematic approach to develop items for a DR-specific QoL item bank. The psychometric properties of the nine QoL subscales will be assessed using Rasch analysis. The resulting validated item bank will allow clinicians and researchers to better understand the QoL impact of DR and DR therapies from the patient's perspective.
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ItemThe impact of diabetic retinopathy on quality of life: qualitative findings from an item bank development project(SPRINGER, 2012-12)PURPOSE: Assessing the efficacy of treatment modalities for diabetic retinopathy (DR) from the patient's perspective is restricted due to a lack of a comprehensive patient-reported outcome measure. We are developing a DR-specific quality of life (QoL) item bank, and we report here on the qualitative results from the first phase of this project. METHODS: Eight focus groups and 18 semi-structured interviews were conducted with 57 patients with DR. The sessions were transcribed verbatim and iteratively analysed using the constant comparative method and NVIVO software. RESULTS: Participants had a median age of 58 years (range 27-83 years). Twenty-seven (47%) participants had proliferative DR in the better eye, and 14 (25%) had clinically significant macular oedema. Nine QoL domains were identified, namely visual symptoms, ocular surface symptoms, vision-related activity limitation, mobility, emotional well-being, health concerns, convenience, social, and economic. Participants described many vision-related activity limitations, particularly under challenging lighting conditions; however, socioemotional issues were equally important. Participants felt frustrated due to their visual restrictions, concerned about further vision loss and had difficulty coping with this uncertainty. Restrictions on driving were pervasive, affecting transport, social life, relationships, responsibilities, work and independence. CONCLUSIONS: Patients with DR experience many socioemotional issues in addition to vision-related activity limitations. Data from this study will be used to generate data for a DR-specific QoL item bank.
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ItemNo Preview AvailableDiabetic Retinopathy and Macular Edema Quality-of-Life Item Banks: Development and Initial Evaluation Using Computerized Adaptive Testing(ASSOC RESEARCH VISION OPHTHALMOLOGY INC, 2017-12)PURPOSE: The purpose of this study was to assess the psychometric properties of diabetic retinopathy (DR) and diabetic macular edema (DME) quality-of-life (QoL) item banks and determine the utility of the final calibrated item banks by simulating a computerized adaptive testing (CAT) application. METHODS: In this clinical, cross-sectional study, 514 participants with DR/DME (mean age ± SD, 60.4 ± 12.6 years; 64% male) answered 314 items grouped under nine QoL item pools: Visual Symptoms (SY); Ocular Comfort Symptoms (OS); Activity Limitation (AL); Mobility (MB); Emotional (EM); Health Concerns (HC); Social (SC); Convenience (CV); and Economic (EC). The psychometric properties of the item pools were assessed using Rasch analysis, and CAT simulations determined the average number of items administered at high and moderate precision levels. RESULTS: The SY, MB, EM, and HC item pools required minor amendments, mainly involving removal of six poorly worded, highly misfitting items. AL and CV required substantial modification to resolve multidimensionality, which resulted in two new item banks: Driving (DV) and Lighting (LT). Due to unresolvable psychometric issues, the OS, SC, and EC item pools were not pursued further. This iterative process resulted in eight operational item banks that underwent CAT simulations. Correlations between CAT and the full item banks were high (range, 0.88-0.99). On average, only 3.6 and 7.2 items were required to gain measurement at moderate and high precision, respectively. CONCLUSIONS: Our eight psychometrically robust and efficient DR/DME item banks will enable researchers and clinicians to accurately assess the impact and effectiveness of treatment therapies for DR/DME in all areas of QoL.