Who Benefits from an Expanding Pool of Matriculants? No abstract available

2015 Glenn A. Fry Award Lecture: Driving toward a New Vision: Understanding the Role of Vision in Driving More than 90% of the sensory information that we use for driving is estimated to be visual. However, there is ongoing debate regarding the extent to which different ocular conditions and types of visual impairment affect driving performance and which visual functions are most important for safe driving. My program of research has sought to address these questions using a range of experimental approaches including measures of real-world driving performance on a closed-circuit driving course and under in-traffic conditions. This article provides a current overview of how visual impairment affects driving ability and safety and also highlights the visual challenges of nighttime driving, including the visibility of vulnerable road users, based on the wider research literature, as well as providing a snapshot of some of my own studies. Emphasis is placed on those studies that are relevant to assessing a patient's visual fitness to drive, as well as providing appropriate advice regarding the impact of common visual impairments on driving ability and safety.

An Analysis of the Optometric Applicant Pool Relative to Matriculants SIGNIFICANCE The interplay of applicants to optometry school and matriculants has not been explored systematically. It is vital that the profession examines these trends to ensure a viable pipeline of future doctors of optometry. PURPOSE The purpose of this study was to describe the demographics and academic qualifications of entering optometry classes from autumn 2010 through autumn 2018 of U.S.-based optometric institutions' application pool and matriculants (enrollees). METHODS Data were gathered from reports generated from accredited schools and colleges of optometry in the United States and compiled by the Association of Schools and Colleges of Optometry (publicly available) and the Optometry Centralized Application Service. Metrics included the annual number of verified applicants, the annual number of matriculants, the home region of U.S.-based applicants, and the Optometry Admission Test (OAT) performance and grade point average of verified applicants. RESULTS The number of verified applicants for autumn 2018 was 0.95% higher than that for autumn 2010, yet the number of matriculants in 2018 compared with 2010 increased by 11.2% with an applicant-to-matriculant ratio in 2010 of 1.53 compared with 1.39 in 2018. Grade point average and academic average OAT scores were stable from 2010 to 2018. The ratios of verified applicants with an academic average OAT score of at least 300 to matriculants were 0.87 for autumn 2018 and 0.92 for autumn 2010. The ratios of verified applicants with a grade point average of at least 3.00 to matriculants were 1.13 for autumn 2018 and 1.23 for autumn 2015. CONCLUSIONS Evidence supports the conclusion that the applicant pool has remained essentially flat for the last decade, whereas the number of matriculants has increased substantially; thus, the number of qualified applicants to matriculants has logically decreased. In the last 2 years, optometric programs have responded by decreasing their institution's number of matriculants to accommodate the national trends.

Association of Total Zinc Intake with Myopia in U.S. Children and Adolescents SIGNIFICANCE This present study advances our knowledge on the role of lifestyle factors in myopia (short-sightedness), specifically dietary factors. It has been suggested in previous studies that lower zinc status is associated with myopia; however, this article shows no relationship between dietary zinc intake and myopia in U.S. adolescents. PURPOSE It has been suggested that low zinc levels may contribute to the development of myopia. The aim of the present study is to examine, for the first time in a Western population, the association of total dietary and supplement zinc intake with myopia. METHODS A total of 1095 children/adolescents aged 12 to 19 years who participated in the U.S. National Health and Nutrition Examination Survey from 2007 to 2008 were enrolled in this study. Multivariate logistic regression analysis was performed to examine the relationship between total zinc intake and myopia after adjustment for potential confounders. In addition, the association between total zinc intake and spherical equivalent refractive error was examined in the myopia group through multiple linear regression. RESULTS Among study participants, 30% were found to be myopic (≤−1.00 D). Although median total daily zinc intake was lower among myopes (10.8 [10.2] mg/d) than among nonmyopes (11.1 [10.8] mg/d), the difference was not statistically significant (P = .11). In multiple logistic regression analyses, zinc and copper intakes were not significantly associated with myopia after adjustment for age, sex, body mass index, ethnicity, family income, recreational activity, copper intake, and daily energy intake (in kilocalories per day). In multiple linear regression, spherical equivalent refractive error was not associated with total zinc intake in the myopic group after adjustment for confounding factors (P = .13). CONCLUSIONS In contrast to previous Asian studies, total zinc intake is not associated with the presence of myopia in U.S. adolescents/children.

Visual Perceptual Skills in Attention-deficit/Hyperactivity Disorder Children: The Mediating Role of Comorbidities SIGNIFICANCE Attention-deficit/hyperactivity disorder (ADHD) has been commonly associated with alterations in visual perception. However, the individual behavior of visual perceptual skills and its relationship with different comorbidities remain unknown. PURPOSE The purpose of this study was to examine whether visual perceptual skills are impaired in children with ADHD, as well as to test the possible mediating role of comorbidities. METHODS Thirty-five nonmedicated ADHD (20 pure and 15 with comorbidities) and 35 age-matched controls completed the performance-based Test of Visual Perceptual Skills. RESULTS The analysis between total ADHD and controls favored the alternative hypothesis (greater values for children with ADHD) for visual memory, spatial relationships, sequential memory, and all the composite measures (Bayes factor [BF] range, 4.26 to 366.85). The analysis between pure ADHD and controls showed that data are more likely under the alternative hypothesis for spatial relationships, sequential memory, overall, basic, and sequencing (BF range, 3.82 to 21.71), whereas the comparison between ADHD with comorbidities and controls additionally favored the alternative hypothesis for visual discrimination (BF = 5.37). Lastly, data from the comparison between pure ADHD and ADHD with comorbidities were insensitive for favoring the null or alternative hypotheses in any subtest or composite scaled score (BF range, 0.33 to 0.66). CONCLUSIONS Our results suggest that some specific patterns of visual perception are altered in ADHD, especially for the total ADHD group. The current findings also evidence that comorbidities play an important role in the association between ADHD and visual perceptual skills. Future studies should address the mediating role of each specific type of comorbidity.

Application of Topographical Keratoconus Detection Metrics to Eyes of Individuals with Down Syndrome SIGNIFICANCE The challenges associated with clinical assessment of individuals with Down syndrome contribute to a wide range of estimates on the prevalence of keratoconus in the Down syndrome population. This work focuses on two topographical indices previously identified with keratoconus detection, applying them to a topographical data set meeting strict sampling criteria. PURPOSE The purpose of this study was to quantify the level of keratoconus-like topographical morphology in a large sample of eyes from individuals with Down syndrome, as identified by two keratoconus detection metrics: inferior-superior dioptric asymmetry (I-S) and KISA%. Severity of the asymmetry was also cast within the context of established Collaborative Longitudinal Evaluation of Keratoconus study disease severity classification criteria. METHODS Corneal topography data on both eyes of 140 subjects with Down syndrome and 138 control subjects were collected. Both I-S and KISA% were calculated from the topography data of eyes with sufficient sampling. Steep and flat keratometry data are reported for subjects with measurements on both eyes in the context of values recorded by the Collaborative Longitudinal Evaluation of Keratoconus study in frank keratoconus to examine within-eye and between-eye asymmetry and severity. RESULTS Keratoconus detection thresholds were exceeded in 20.8% of the eyes of subjects with Down syndrome and 2.2% of the eyes of controls using I-S and 11.8% of the eyes of subjects with Down syndrome and 0.0% of the eyes of controls using KISA%. Examination of the level of intraeye difference between flat and steep keratometry data for individuals with Down syndrome detected as having corneal morphology consistent with moderate keratoconus yields an average of 1.81 D of toricity, whereas the Collaborative Longitudinal Evaluation of Keratoconus study reported 3.28 D of toricity. CONCLUSIONS Morphology consistent with keratoconus as codified in the detection metrics I-S and KISA% is present in a large percentage of the eyes of individuals with Down syndrome. Differences were observed in the distribution of severity of corneal morphology in individuals with Down syndrome and the keratoconus population at large.

Comparison of Dynamic Retinoscopy and Autorefraction for Measurement of Accommodative Amplitude SIGNIFICANCE This study promotes the use of dynamic retinoscopy to obtain objective measures of accommodative amplitude (AA) in the clinical setting in lieu of the subjective push-up technique. PURPOSE This study compared the agreement between open-field autorefraction and a modified dynamic retinoscopy for the objective measurement of AA. METHODS Accommodative amplitude was measured using two objective techniques for subjects aged 5 to 60 years. Test order was randomized and monocular AA was measured as subjects viewed printed letters 0.9 mm in height with their dominant eye and distance refraction. For retinoscopy, subjects held a near rod and viewed the target at the nearest (most proximal) point of clear vision. The examiner then performed dynamic retinoscopy along the horizontal meridian and identified the physical location of neutrality of the reflex, which was converted to AA in diopters. Autorefraction was performed obtaining repeated measures of refraction beginning from a target demand of 2.5 D and increasing in discrete steps until there was no subsequent increase in accommodative response. Refractions were converted to power in the horizontal meridian and expressed as accommodation in diopters with the maximal value termed the AA. Distance overrefractions were measured for both techniques to adjust AA for any uncorrected refractive error. Difference versus mean analysis was used to compare agreement between tests. RESULTS The 95% limits of agreement between techniques were calculated after removal of two young outliers who responded poorly to one of the techniques. The overall mean difference for 95 subjects was 0.02 ± 0.97 D, with limits of agreement spanning −1.87 to 1.92 D. No significant linear relationship between the magnitude of the AA and the differences between techniques was observed. CONCLUSIONS Agreement between dynamic retinoscopy and open-field autorefraction was less than 2 D with no systematic bias, suggesting that dynamic retinoscopy may be a suitable clinical technique to measure objective AA.

The Tear Function in Electronic Cigarette Smokers SIGNIFICANCE Prominent ocular surface dryness and poor tear film quality among electronic cigarette (e-cigarette) smokers (or vapers) indicate potential harm to the eyes from vaping. These findings may serve as precautionary signs for e-cigarette users and exposed bystanders. PURPOSE Little is known about the effect of e-cigarettes on the eyes except for reported eye irritation among individuals who were exposed to e-cigarette vapors and e-liquids. This study aims to investigate the effect of vaping on ocular surface health of long-term vapers. METHODS Twenty-one vapers and 21 healthy nonsmokers who are all male underwent measurements of the Ocular Surface Disease Index, noninvasive tear breakup time, fluorescein breakup time, ocular surface staining, tear meniscus height, and the Schirmer test. The effect of voltage used during vaping was also evaluated against the measurements. RESULTS Vapers experienced moderate-to-severe eye dryness (25.0 [interquartile range, 14.6 to 43.7]) as indicated by the Ocular Surface Disease Index. Significant reductions of noninvasive tear breakup time (3.13 ± 0.97 vs. 6.57 ± 2.31 seconds; P < .0001), fluorescein breakup time (2.68 [interquartile range, 2.33 to 3.18] vs. 4.12 [3.56 to 5.07] seconds; P < .0001), and tear meniscus height (203.0 [193.0 to 225.5] vs. 235.0 [210.0 to 253.50] μm; P = .002) were noted in vapers, but the Schirmer test showed higher results (14.5 [12.0 to 17.0] vs. 8.0 [7.0 to 11.0] mm; P = .001) compared with nonsmokers. Increase in vaping voltage aggravated the dry eye symptoms and tear instability (P < .05). Higher Schirmer test result was also noted as voltage increases. CONCLUSIONS Vapers showed moderate-to-severe symptomatic dry eye and poorer tear film quality compared with nonsmokers. High vaping voltage may have aggravated the dry eye syndrome because of hazardous by-products from pyrolysis of the e-liquid constituents. Investigation of the ocular surface health at cellular and molecular levels is warranted to gain a deeper understanding on the effect of e-cigarette to the eyes.

Visual Prognosis in the Better-seeing Eyes of Patients with Unilateral Polypoidal Choroidal Vasculopathy SIGNIFICANCE In patients initially diagnosed as having unilateral polypoidal choroidal vasculopathy, the visual prognosis of the better-seeing eye is highly favorable. If patients are overly pessimistic regarding their vision in the future, physicians can encourage patients by informing them of the small possibility for visual deterioration in the better-seeing eye. PURPOSE The purpose of this study was to investigate the long-term changes in the visual acuity of the better-seeing eyes in patients with unilateral polypoidal choroidal vasculopathy. METHODS This retrospective, single-institution study was performed with 221 patients who were diagnosed as having unilateral polypoidal choroidal vasculopathy and who were treated with intravitreal anti–vascular endothelial growth factor. Only patients with an initially uninvolved eye best-corrected visual acuity (BCVA) of 20/40 or better and who were followed up for at least 24 months were included. The changes in the BCVAs of the initially involved and uninvolved eyes as well as the better-seeing eyes were measured. For patients with three or more lines of uninvolved eye visual deterioration, the cause for the visual deterioration was identified. RESULTS Patients were followed up for a mean of 43.1 ± 11.8 months after diagnosis. During the follow-up period, three or more lines of deterioration in the BCVA were noted in 61 initially involved eyes (27.6%) and 11 uninvolved eyes (4.9%). The reasons for uninvolved eye visual deterioration were neovascularization (n = 8), retinal vein occlusion (n = 2), and posterior capsule opacification (n = 1). At diagnosis, the BCVA of the better-seeing eye was 0.05 ± 0.08 (Snellen equivalents, 20/22). During the follow-up period, three or more lines of deterioration in the BCVA for the better-seeing eye were noted in eight patients (3.6%). CONCLUSIONS Visual acuity of the better-seeing eye over time remained stable in most patients who were initially diagnosed as having unilateral polypoidal choroidal vasculopathy. As a result, the visual prognosis of the better-seeing eye is highly favorable in this condition.

Limitations and Precautions in the Use of the Farnsworth-Munsell Dichotomous D-15 Test SIGNIFICANCE Clinicians who administer the Farnsworth-Munsell D-15 test need to pay attention to the quality and quantity of lighting and the time that they allow for completion of the test, and all repeat attempts need to be included in reports on compliance with color vision standards. PURPOSE The validity of the Farnsworth-Munsell D-15 has been questioned because practice may allow significantly color vision–deficient subjects to pass. In this article, we review the influence of practice and other factors that may affect the performance. These relate to both the design and the administration of the test. METHODS We review the literature and present some calculations on limitations in the colorimetric design of the test, quantity and quality of lighting, time taken, and repeat attempts. RESULTS In addition to the review of the literature, color differences and luminance differences under selected sources are calculated, and the increases in luminance clues under some sources and for protanopes are illustrated. CONCLUSIONS All these factors affect the outcome of the test and need specification and implementation if the test is to be applied consistently and equitably. We recommend the following: practitioners should never rely on a single color vision test regardless of the color vision standard; lighting should be Tcp ′′ 6500 K and Ra > 90; illuminance levels should be between 200 and 300 lux if detection of color vision deficiency is a priority or between 300 and 1000 lux if the need is to test at the level where illuminance has minimal influence on performance; illuminance should be reported; time limits should be set between 1 and 2 minutes; repeat testing (beyond the specified test and one retest) should be carried out only with authorization; and initial and repeated results should be reported. A set of test instructions to assist in the consistent application of the test is provided in the Appendix.