Management Of Age-related Macular Degeneration Research Articles

Chromatic and flicker threshold changes in age-related macular degeneration following anti-VEGF treatment

ABSTRACT Clinical relevance Red-green chromatic sensitivity and photopic (cone-mediated) flicker sensitivity showed marked improvement after anti-VEGF treatment. The use of flicker and chromatic sensitivities as potential functional tests to monitor treatment outcomes in age-related macular degeneration highlights the clinical importance. Background High-contrast visual acuity (VA) is not a sensitive clinical marker in the management of age-related macular degeneration (AMD). Therefore, flicker and chromatic sensitivity changes were assessed following anti-VEGF treatment in subjects with neovascular AMD. Methods Subjects diagnosed with neovascular AMD were recruited. VA was measured using a COMPlog chart. Flicker (in central 5°) and chromatic thresholds (red-green and yellow-blue) were measured using Flicker-plus test and Colour Assessment and Diagnosis (CAD) tests, respectively. Baseline thresholds and foveal thickness were measured on the same day, just before anti-VEGF injection delivery and 5 weeks ± 5 days later. Results Thirteen subjects (8 males, 5 females) with a mean age of 67.5 ± 8.2 years completed the study. Median VA was not significantly different post-treatment (0.57 logMAR [~6/22: Snellen equivalent], IQR: 0.33) compared to baseline (0.56 logMAR, IQR: 0.33), Wilcoxon matched-pair test, p = 0.55). Median Red-Green thresholds improved significantly post-treatment (22.15 CAD units, IQR: 26.06, n = 9), compared to baseline (24.24 CAD units, IQR: 26.21, p = 0.02). Median photopic and mesopic FMT did not show significant change post treatment compared to baseline (p > 0.01, statistical significance of p-value corrected for multiple comparisons was set to 0.01). Similarly, the foveal thickness was not significantly different at post-treatment visit than baseline (p = 0.53). Conclusion Red/green sensitivity recovered better than yellow/blue sensitivity, thus, providing insight into recovery mechanisms in AMD and usefulness of these tests as clinical markers in the management of AMD.

Hyperbaric Oxygen Effects on Contrast and Macular Light Sensitivity in Dry Type Age-Related Macular Degeneration Patients

This study was to compare the effectiveness of hyperbaric oxygen therapy (HBOT) on contrast and macular light sensitivity improvement in dry type age-related macular degeneration (AMD) patients. The subjects were eyes that had been diagnosed with dry type AMD which met inclusion criteria. The subjects were divided into two groups. The first group was given antioxidants and HBOT. The second group was given only antioxidants. Contrast and macular light sensitivity test were done using MARS contrast sensitivity chart and Humphrey Field Analyzer-3 for three times, pre-therapy, day-1 and 14 post- therapy. This study found that 25 eyes were included for analysis, 14 subjects in first group, and 11 subjects in second group. Statistical analysis results showed that there were significant increase on contrast sensitivity in intervention group between one-day post-therapy with pre-therapy, P = 0.003 (P <0.05), and between 14-days post-therapy with pre-therapy, P = 0,015 (P <0.05). From pre- and post-analysis, there were no significant difference found on contrast sensitivity in control group and macular light sensitivity in intervention group. In control group, there were significant increase on superotemporal, superonasal, and inferonasal area between one-day post-therapy and pra-therapy with P = 0.004, P = 0.013 and P = 0.008 (P <0.05), respectively, and there was significant decrease on inferonasal area between 14-days post-therapy and one-day post-therapy, P = 0.003 (P <0.05). In conclusion, patients with AMD who were subjected to HBOT achieved improvement in contrast sensitivity in cases considered as having low prognosis. HBOT should be considered as promising intervention for AMD management adjuvant and further research are needed to find optimal dosage.

Étude des récidives exsudatives chez 42 yeux naïfs atteints de dégénérescence maculaire liée à l’âge suivis plus de 2 ans

The objective of this study was to analyze the reproducibility or variability of the time period to exudative recurrences in patients who were treated with intravitreal injections (IVT) of anti-VEGF (ranibizumab, aflibercept) for exudative age-related macular degeneration (AMD). The data studied included the number of recurrences per year, the time between the last IVT and the recurrence, fluctuation over time in the same patient, and changes in the therapeutic management of these exudative recurrences with regard to repeat induction therapy of three IVT, changes in monitoring protocols, and switches in anti-VEGF molecules. We conducted a retrospective, single center, "real-life" study at the Nantes University Hospital, including 33 patients (42 eyes) between March 2012 and March 2017. These were IVT-naive patients, in whom anti-VEGF IVT treatment was initiated for management of exudative AMD, with a follow-up period of at least two consecutive years. The main outcome was the fluctuation in recurrences times for the same patient. Of the 33 patients included, 9 had bilateral involvement, for a total of 42 eyes. Twenty were women (60.6%), the median age at inclusion was 78.5 years with a follow-up period of 3.7 years. The average time to recurrence was 11.6 weeks after the last IVT. The first recurrence occurred within 9.8 weeks after the last IVT. 12.3% of the eyes had consisent recurrence times, with fluctuations of less than 2 weeks between the various relapses over the two years of follow-up. a total of 7.1% of the eyes had no exudative recurrences during follow-up. The first exudative recurrence occurred at a mean of 38.2 weeks after diagnosis of the disease, or 37.2 weeks after the first IVT. 14.3% of the recurrences led to the administration of a repeat induction of three intravitreal anti-VEGF injections, 8.6% led to a change in anti-VEGF molecule, and 7.1% to a modification of the treatment protocol. The goal of this study was to analyze the variability of the time to exudative recurrence in patients treated with anti-VEGF IVT in the context of exudative AMD, because, since the advent of anti-VEGF IVT in 2007, few data have been available on long-term follow-up and fluctuations in recurrence times in patients who will receive treatment for several years. Recurrences times are not reproducible over follow-up, particularly in patients experience their first exudative recurrence beyond 8 weeks and in patients with multiple exudative recurrences.

Artificial Intelligence (AI) Applications for Age-Related Macular Degeneration (AMD) and Other Retinal Dystrophies

ABSTRACT Artificial intelligence (AI), with its subdivisions (machine and deep learning), is a new branch of computer science that has shown impressive results across a variety of domains. The applications of AI to medicine and biology are being widely investigated. Medical specialties that rely heavily on images, including radiology, dermatology, oncology and ophthalmology, were the first to explore AI approaches in analysis and diagnosis. Applications of AI in ophthalmology have concentrated on diseases with high prevalence, such as diabetic retinopathy, retinopathy of prematurity, age-related macular degeneration (AMD), and glaucoma. Here we provide an overview of AI applications for diagnosis, classification, and clinical management of AMD and other macular dystrophies.

Spatio-temporal alterations in retinal and choroidal layers in the progression of age-related macular degeneration (AMD) in optical coherence tomography

Age-related macular degeneration (AMD) is the predominant cause of vision loss in the elderly with a major impact on ageing societies and healthcare systems. A major challenge in AMD management is the difficulty to determine the disease stage, the highly variable progression speed and the risk of conversion to advanced AMD, where irreversible functional loss occurs. In this study we developed an optical coherence tomography (OCT) imaging based spatio-temporal reference frame to characterize the morphologic progression of intermediate age-related macular degeneration (AMD) and to identify distinctive patterns of conversion to the advanced stages macular neovascularization (MNV) and macular atrophy (MA). We included 10,040 OCT volumes of 518 eyes with intermediate AMD acquired according to a standardized protocol in monthly intervals over two years. Two independent masked retina specialists determined the time of conversion to MNV or MA. All scans were aligned to a common reference frame by intra-patient and inter-patient registration. Automated segmentations of retinal layers and the choroid were computed and en-face maps were transformed into the common reference frame. Population maps were constructed in the subgroups converting to MNV (n=135), MA (n=50) and in non-progressors (n=333). Topographically resolved maps of changes were computed and tested for statistical significant differences. The development over time was analysed by a joint model accounting for longitudinal and right-censoring aspect. Significantly enhanced thinning of the outer nuclear layer (ONL) and retinal pigment epithelium (RPE)–photoreceptorinner segment/outer segment (PR-IS/OS) layers within the central 3 mm and a faster thinning speed preceding conversion was documented for MA progressors. Converters to MNV presented an accelerated thinning of the choroid and appearance changes in the choroid prior to MNV onset. The large-scale automated image analysis allowed us to distinctly assess the progression of morphologic changes in intermediate AMD based on conventional OCT imaging. Distinct topographic and temporal patterns allow to prospectively determine eyes with risk of progression and thereby greatly improving early detection, prevention and development of novel therapeutic strategies.

Digital Technology for AMD Management in the Post-COVID-19 New Normal.

The COVID-19 pandemic has put strain on healthcare systems and the availability and allocation of healthcare manpower, resources and infrastructure. With immediate priorities to protect the health and safety of both patients and healthcare service providers, ophthalmologists globally were advised to defer nonurgent cases, while at the same time managing sight-threatening conditions such as neovascular Age-related Macular Degeneration (AMD). The management of AMD patients both from a monitoring and treatment perspective presents a particular challenge for ophthalmologists. This review looks at how these pressures have encouraged the acceptance and speed of adoption of digitalization. A literature review was conducted on the use of digital technology during COVID-19 pandemic, and on the transformation of medicine, ophthalmology and AMD screening through digitalization. In the management of AMD, the implementation of artificial intelligence and "virtual clinics" have provided assistance in screening, diagnosis, monitoring of the progression and the treatment of AMD. In addition, hardware and software developments in home monitoring devices has assisted in self-monitoring approaches. Digitalization strategies and developments are currently ongoing and underway to ensure early detection, stability and visual improvement in patients suffering from AMD in this COVID-19 era. This may set a precedence for the post COVID-19 new normal where digital platforms may be routine, standard and expected in healthcare delivery.

Ocular Imaging for Enhancing the Understanding, Assessment, and Management of Age-Related Macular Degeneration.

Age-related macular degeneration (AMD) is a progressive neuro-retinal disease and the leading cause of central vision loss among elderly individuals in the developed countries. Modern ocular imaging technologies constitute an essential component of the evaluation of these patients and have contributed extensively to our understanding of the disease. A challenge with any review of ocular imaging technologies is the rapid pace of progress and evolution of these instruments. Nonetheless, for proper and optimal use of these technologies, it is essential for the user to understand the technical principles underlying the imaging modality and their role in assessing the disease in various settings. Indeed, AMD, like many other retinal diseases, benefits from a multimodal imaging approach to optimally characterize the disease. In this chapter, we will review the various imaging technologies currently used in the assessment and management of AMD.

Therapeutic Options Under Development for Nonneovascular Age-Related Macular Degeneration and Geographic Atrophy.

Age-related macular degeneration (AMD) is a chronic, multifactorial disease and a leading cause of irreversible blindness in the elderly population in the Western Hemisphere. Among the two major subtypes of AMD, the prevalence of the nonneovascular (dry) type is approximately 85-90% and the neovascular (wet) type is 10-15%. Healthy lifestyle and nutritional supplements of anti-oxidative micronutrients have been shown to delay the progression of dry AMD and lower the risk of development of wet AMD, and anti-vascular endothelial growth factor (anti-VEGF) injections have been shown to improve visual acuity for wet AMD patients. However, to date, there is no approved treatment for geographic atrophy (GA), a debilitating late stage of dry AMD. Thus, this represents a large unmet need in this patient population. This review focuses on the current management and treatment of nonneovascular AMD, the drugs and devices that have been under investigation for the treatment of GA, and the latest clinical trial results. A few therapeutic options have shown initial promising clinical trial results, but failed to show efficacy in larger trials, while others are awaiting future clinical trial results and long-term follow-up to evaluate safety and efficacy.

Optical Coherence Tomography Angiography in Intermediate and Late Age-Related Macular Degeneration: Review of Current Technical Aspects and Applications

Optical coherence tomography angiography (OCTA) is a non-invasive diagnostic instrument that has become indispensable for the management of age-related macular degeneration (AMD). OCTA allows quickly visualizing retinal and choroidal microvasculature, and in the last years, its use has increased in clinical practice as well as for research into the pathophysiology of AMD. This review provides a discussion of new technology and application of OCTA in intermediate and late AMD.

Exudative non-neovascular age-related macular degeneration.

To describe the clinical and multimodal imaging (MMI) features of age-related macular degeneration (AMD) eyes presenting with intraretinal exudation and no evidence of neovascularization or structural alterations of native retinal vessels. This was a retrospective review of the MMI and electronic health records for 3 consecutive patients presenting with unilateral exudative non-neovascular age-related macular degeneration. MMI included confocal color fundus photography (CFP), fundus autofluorescence (FAF), fluorescein angiography (FA), spectral domain optical coherence tomography (SD-OCT), swept-source optical coherence tomography angiography (SS-OCTA), and spectral domain optical coherence tomography angiography (SD-OCTA). Dense B-scan OCTA (DB-OCTA) patterns and implemented image post-processing were used to improve spatial resolution in the OCTA analysis and remove projection artifacts. Three eyes of 3 patients (1 male and 2 females, ages 72-87) developed intraretinal fluid (IRF) producing retinal edema during regular follow-up for non-neovascular AMD. FA, SS-OCTA, and DB-OCTA demonstrated no evidence of macular neovascularization or discrete retinal vascular abnormalities that could explain the IRF accumulation. Two eyes received intravitreal anti-VEGF therapy and demonstrated prompt resolution of IRF with periodic recurrences over time. Exudative non-neovascular AMD is a novel clinical phenotype characterized by the presence of non-neovascular intraretinal exudation producing macular edema. Differentiating this condition from other manifestations of AMD requires appropriate use of MMI. Further study is needed to assess the clinical impact and optimal management of exudative non-neovascular AMD.

Effect of intravitreal anti-vascular endothelial growth factor administration on the vitreomacular interface and retinal morphology in eyes with neovascular age-related macular degeneration

To assess the effect of intravitreal anti-vascular endothelial growth factor (anti-VEGF) administration on the vitreomacular interface and retinal morphology in eyes with neovascular age-related macular degeneration (AMD) and to identify morphological markers potentially influencing disease prognosis. A total of 43 patients (51 eyes) with treatment-naive neovascular AMD subsequently treated with bevacizumab 1.25 mg (in 0.05 ml of solution) were monitored until month 12 of follow-up. Following a loading dose of three monthly intravitreal anti-VEGF injections, patients were treated as-needed (pro re nata [PRN]). Functional and morphological changes were assessed using spectral domain optical coherence tomography (SD-OCT). All study eyes showed evidence of an increase in the frequency of geographic atrophy (GA) occurrence during follow-up compared to baseline (n = 23 [45%] at month 12 compared to n = 5 [9.8%] at baseline [p > 0.05]). There was a trend towards more frequent GA in eyes diagnosed with posterior vitreomacular adhesion (PVA) at baseline that developed posterior vitreous detachment (PVD) during follow-up compared to eyes not developing PVD (35% vs. 44% GA, p 0.56). Alterations of the vitreomacular interface and retinal morphology in patients with neovascular AMD treated with bevacizumab may have a significant effect on prognosis with respect to GA development. Eyes with vitreomacular adhesion at baseline developing GA during follow-up might require more intensive anti-VEGF therapy with a decreased ability to extend treatment intervals. Findings are comparable to eyes treated with other anti-VEGF agents administered for the management of neovascular AMD.

Clinical audit as an educative tool for optometrists: an intervention study in age-related macular degeneration.

Age-related macular degeneration (AMD) is a major cause of vision loss. This study investigated whether performing clinical audit and receiving analytical performance feedback altered documentation of the AMD care provided by optometrists. Australian optometrists were recruited and completed a survey about their demographics and confidence in AMD care, and a three-month audit of their practice records using an AMD audit tool (termed the pre-audit evaluation). After receiving analytical feedback, participants identified areas for improvement and re-audited their practices after three months to analyse changes in performance (termed the post-audit evaluation). Paired t-tests and Wilcoxon signed-rank tests, as appropriate, were used to compare pre- and post-audit data. Twenty optometrists, most practising in Victoria, Australia, completed the study. Participants primarily worked in corporate practice and/or rural settings and had a range of optometric experience (2-40years). At baseline, participants felt confident in their: knowledge of AMD risk factors (65%), advice to patients about these factors (55%) and management of earlier stages of AMD (55%). Each clinician completed (median [IQR]): 15 [IQR: 10-19] and 12 [IQR: 8-16] audits of unique patient records, pre- and post-audit, respectively. Post-audit, average record documentation (per optometrist) improved for asking about: AMD family history (94% to 100%, p=0.03), smoking status (21% to 58%, p<0.01), diet (11% to 29%, p<0.01) and nutritional supplementation (20% to 51%, p<0.01). For clinical examination, compliance with documenting pinhole visual acuity, performing an in-office Amsler grid (upon indication) and using optical coherence tomography improved post-audit (p<0.05). Accuracy of severity documentation improved for earlier stages of AMD (p<0.05). For earlier stages of AMD, documentation of counselling about modifiable risk factors significantly improved post-audit (p<0.05). Aspects well-performed pre-audit that did not change included documenting: medical histories (100% at both time points, p=0.06) and retinal imaging (77% at both time points, p=0.97). Self-audit with analytical feedback improved clinical record documentation of: AMD risk factors, clinical examination, AMD severity classification and management advice. These findings support a role for audit to improve optometric clinical care of AMD, as evidenced by improved documentation of the AMD care delivered.

Neovascular Age-Related Macular Degeneration: Therapeutic Management and New-Upcoming Approaches.

Age-related macular degeneration (AMD) constitutes a prevalent, chronic, and progressive retinal degenerative disease of the macula that affects elderly people and cause central vision impairment. Despite therapeutic advances in the management of neovascular AMD, none of the currently used treatments cures the disease or reverses its course. Medical treatment of neovascular AMD experienced a significant advance due to the introduction of vascular endothelial growth factor inhibitors (anti-VEGF), which dramatically changed the prognosis of the disease. However, although anti-VEGF therapy has become the standard treatment for neovascular AMD, many patients do not respond adequately to this therapy or experience a slow loss of efficacy of anti-VEGF agents after repeated administration. Additionally, current treatment with intravitreal anti-VEGF agents is associated with a significant treatment burden for patients, caregivers, and physicians. New approaches have been proposed for treating neovascular AMD. Among them, designed ankyrin repeat proteins (DARPins) seem to be as effective as monthly ranibizumab, but with greater durability, which may enhance patient compliance with needed injections.

Gene, Cell and Antibody-Based Therapies for the Treatment of Age-Related Macular Degeneration.

Here we discuss antibody, cell and gene-based therapies that are currently available and under investigation for both wet and dry age-related macular degeneration (AMD). We initially discuss ocular anatomy, AMD modelling as well as the underlying pathophysiology of AMD. The antibody-based trials which have revolutionised the management of wet AMD are reviewed. The latest concepts in antibody therapy for wet AMD such as the port delivery systems, bispecific antibodies, designed ankyrin repeat protein (DARPINs) and brolucizumab are explored. Furthermore, the antibody-based trials targeting the complement pathway to reduce progression of geographic atrophy (GA) in dry AMD are discussed. Stem cell therapy and gene therapy are novel treatment modalities with no established clinical use in wet or dry AMD. Here, we discuss their efficacy so far in clinical trials. Their benefits and risk in the treatment of both wet and dry AMD are evaluated.

Age-related macular degeneration (AMD): More than meets the eye. The role of multimodal imaging in today's management of AMD-A review.

Multimodal imaging (MMI) allows a more granular grading of age-related macular degeneration (AMD) disease severity, with many novel risk factors having been recently identified. With this imaging information, we are better able to counsel our patients with more accurate and individualized progression scenarios. MMI also allows identification of anatomical features that increase our understanding of disease processes involved in progression to late AMD. Treatment protocols for neovascular AMD (nAMD) depend largely on the optical coherence tomography (OCT) appearance to determine disease activity, which allows us to individualize treatment. In geographic atrophy (GA), new intervention trials require the ability to define the extent of GA, so that GA growth rate can be determined. This is achieved through fundus autofluorescence (FAF) imaging, which allows greater accuracy of border identification, as well as revealing FAF patterns predictive of growth rates. As we strive to bring interventions earlier in the disease course, OCT imaging provides an ability to identify the first signs of atrophy, which may serve as novel surrogate biomarkers for GA, thereby facilitating trials. In the future, the use of artificial intelligence (AI) to automatically identify relevant features on MMI could further enhance our ability to determine disease severity, predict progression and assist in identifying disease activity parameters to support clinical decision making when treating nAMD. Newer developments may allow frequent, remote capturing of images, reducing clinic visits, detecting progression and monitoring neovascular activity in-between clinic visits. Being aware of these new imaging insights in AMD, greatly enhance our clinical management of AMD.

Unsupervised Super-Resolution of OCT Images Using Generative Adversarial Network for Improved Age-Related Macular Degeneration Diagnosis

Age-related macular degeneration (AMD) is the leading cause of progressive vision loss in the elderly. Optical coherence tomography (OCT) is a promising diagnostic tool for early detection and management of AMD. However, the speckle noise and low resolution (LR) of the OCT images affect its diagnostic viabilities. Therefore, denoising and super-resolution (SR) techniques present a potential solution to improve the quality of the OCT images. Recent methods rely on example-based approaches that require paired LR and high resolution (HR) images for training. However, the large scale acquisition of paired LR-HR images presents pertinent challenges in clinical settings. Therefore, this work proposes an unsupervised framework using the generative adversarial network (GAN) to perform fast and reliable SR without the requirement of aligned LR-HR pairs. We use adversarial learning with cycle consistency and identity mapping priors to preserve the spatial correlation, color and texture details in the generated clean HR images. Experimental results on clinical-grade OCT images show that the proposed method outperforms the existing methods both in terms of SR performance and computational time. Improved classification accuracy of 96.54% is obtained when the generated images are used for automated AMD diagnosis. The enhanced generalizability and faithful reconstruction attributes make the proposed method suitable for assisting ophthalmologists in better diagnosis and treatment planning.

Recent theranostic paradigms for the management of Age-related macular degeneration

Degenerative diseases of eye like Age-related macular degeneration (AMD), that affects the central portion of the retina (macula), is one of the leading causes of blindness worldwide especially in the elderly population. It is classified mainly as wet and dry form. With expanding knowledge about the underlying pathophysiology of the disease, various treatment strategies are being employed to halt the course of the disease progression. Hitherto, there is no ideal therapy which can cure the disease completely, and targeting the posterior segment of the eye is yet another challenge. The purpose of this review is to summarize the recent advances in the management and treatment stratagems (therapies, delivery systems and diagnostic tools) pertaining to AMD viz. molecular targeting, stem cell therapy, nanotechnology and exosomes with special reference to newer technologies like artificial intelligence and 3D printing. Furthermore, the role of diet and nutritional supplements in the prevention and treatment of the disease has also been highlighted. The alarming increase in the said disorder around the globe demands exhaustive research and investigations in the treatment zone. This review thus additionally directs the attention towards the challenges and future perspectives of different treatment approaches for AMD.

Autophagy Upregulation by the TFEB Inducer Trehalose Protects against Oxidative Damage and Cell Death Associated with NRF2 Inhibition in Human RPE Cells.

Trehalose is a natural dietary molecule that has shown antiaging and neuroprotective effects in several animal models of neurodegenerative diseases. The role of trehalose in the management of age-related macular degeneration (AMD) is yet to be investigated and whether trehalose could be a remedy for the treatment of diseases linked to oxidative stress and NRF2 dysregulation. Here, we showed that incubation of human retinal pigment epithelial (RPE) cells with trehalose enhanced the mRNA and protein expressions of TFEB, autophagy genes ATG5 and ATG7, as well as protein expressions of macroautophagy markers, LC3B and p62/SQTM1, and the chaperone-mediated autophagy (CMA) receptor LAMP2. Cathepsin D, a hydrolytic lysosomal enzyme, was also increased by trehalose, indicating higher proteolytic activity. Moreover, trehalose upregulated autophagy flux evident by an increase in the endogenous LC3B level, and accumulation of GFP-LC3B puncta and free GFP fragments in GFP-LC3 – expressing cells in the presence of chloroquine. In addition, the mRNA levels of key molecular targets implicated in RPE damage and AMD, such as vascular endothelial growth factor- (VEGF-) A and heat shock protein 27 (HSP27), were downregulated, whereas NRF2 was upregulated by trehalose. Subsequently, we mimicked in vitro AMD conditions using hydroquinone (HQ) as the oxidative insult on RPE cells and evaluated the cytoprotective effect of trehalose compared to vehicle treatment. HQ depleted NRF2, increased oxidative stress, and reduced the viability of cells, while trehalose pretreatment protected against HQ-induced toxicity. The cytoprotection by trehalose was dependent on autophagy but not NRF2 activation, since autophagy inhibition by shRNA knockdown of ATG5 led to a loss of the protective effect. The results support the transcriptional upregulation of TFEB and autophagy by trehalose and its protection against HQ-induced oxidative damage in RPE cells. Further investigation is, therefore, warranted into the therapeutic value of trehalose in alleviating AMD and retinal diseases associated with impaired NRF2 antioxidant defense.

Renin-Angiotensin System Inhibitor Usage and Age-Related Macular Degeneration among Hypertensive Patients: Results from the National Health and Nutrition Examination Survey, 2005-2008.

Purpose To assess whether renin-angiotensin system inhibitor (RASI) utilization is associated with age-related macular degeneration (AMD) prevalence among hypertensive patients. Methods A US population-based, cross-sectional study was conducted. 3,023 hypertensive participants aged 40 years and older with gradable retinal images and ascertained RASI usage in the National Health and Nutrition Examination Survey (NHANES), 2005–2008, were finally enrolled into the study. RASI usage was obtained by interview, and AMD was determined through retinal image assessment. We performed multivariable analyses to assess the relationship between utilization of RASIs and AMD prevalence. We also took drug treatment duration into account, in order to better understand the effects of RASIs. Results Multivariable logistic regression analyses revealed that AMD prevalence had no significant association with RASI usage but was inversely correlated with RASI treatment duration (odds ratio (OR) = 0.87, 95% confidence interval (CI) = 0.78–0.98, p=0.02). Long-term usage (>5 years) of RASIs was significantly associated with not only reduced overall risk of AMD (OR = 0.23, 95% CI = 0.14–0.38, p < 0.001) but also lower propensity to have early (OR = 0.23, 95% CI = 0.14–0.37, p < 0.001) and late (OR = 0.25, 95% CI = 0.07–0.87, p=0.03) AMD. Furthermore, long-term RASI users were less prone to develop soft drusen (OR = 0.67, 95% CI = 0.45–0.99, p=0.04) and geographic atrophy (GA) (OR = 0.39, 95% CI = 0.22–0.71, p=0.003). Conclusions Evidence supporting that RASI utilization could directly protect against AMD in hypertensive patients was still insufficient, but long-term RASI treatment seemed to be beneficial for both early and late AMD, implicating a promising therapeutic approach that RASIs might offer for AMD prevention and management.

Optometry Australia's chairside reference for the diagnosis and management of age‐related macular degeneration

Age‐related macular degeneration (AMD) is the leading cause of irreversible vision loss in people over the age of 50-years in Australia. Optometry Australia has developed this AMD chairside reference in consultation with a member‐based working group comprised of experienced practitioners. It provides an evidence‐based approach to current best practice in the diagnosis and management of AMD. Optometrists should be competent in assessing patients with or at risk of developing AMD, so that they are able to provide evidence‐based management including appropriate communication, diagnosis and referral when indicated. This AMD chairside reference covers risk factors for the development of AMD or progression to late‐stage AMD; the current clinical classification of AMD; common signs and symptoms; optometric assessment including ocular imaging and biomarkers; differential diagnoses; and management of early, intermediate and late AMD. Optometry Australia's chairside reference is intended as a general guide for optometrists, and is not a formal management protocol.