Veterans Affairs Low-vision Intervention Trial II: One-year Follow-up SIGNIFICANCE One-year follow-up is recommended for patients with macular diseases to assess functional changes associated with disease progression and to modify low-vision (LV) treatment plans, if indicated. PURPOSE The purpose of this study was to observe 255 patients with macular diseases who received LV rehabilitation (rehabilitation with a therapist) or basic LV services (LV devices dispensed without therapy) during Veterans Affairs Low-vision Intervention Trial II after the trial ended at 4 months until 1-year follow-up. METHODS The primary outcome measure was visual ability measured with the 48-item Veterans Affairs Low-vision Visual Functioning Questionnaire. Mean visual ability scores for the treatment groups were compared from baseline to 4 months, 4 months to 1 year, and baseline to 1 year. Changes from baseline to 1 year were compared between the two groups. Predictors of changes in visual ability from 4 months to 1 year were assessed using linear regression. RESULTS Both groups experienced significant improvement in all measures of visual ability from baseline to 1 year but lost visual reading ability during the observation period (LV rehabilitation group, −0.64 [1.2] logit; 95% confidence interval [CI], −0.84 to −0.44 logit; basic LV group, −0.63 [1.4] logit; 95% CI, −0.88 to −0.38 logit), and overall visual ability was lost in the LV rehabilitation group (−0.20 [0.8] logit; 95% CI, −0.34 to −0.06 logit). Loss of visual reading ability in both groups from 4 months to 1 year was predicted by reading ability scores at 4 months, loss of near visual acuity from 4 months to 1 year, and lower EuroQol-5D utility index scores; loss of overall visual ability in the LV rehabilitation group during the same time period was predicted by lower overall ability scores at 4 months. CONCLUSIONS Visual ability significantly improved in all groups from baseline to 1 year. However, the loss of visual reading ability experienced by both groups from 4 months to 1 year reduced the benefit of the services provided.

Validation of an Affordable Handheld Wavefront Autorefractor SIGNIFICANCE There is a critical need for tools that increase the accessibility of eye care to address the most common cause of vision impairment: uncorrected refractive errors. This work assesses the performance of an affordable autorefractor, which could help reduce the burden of this health care problem in low-resource communities. PURPOSE The purpose of this study was to validate the commercial version of a portable wavefront autorefractor for measuring refractive errors. METHODS Refraction was performed without cycloplegia using (1) a standard clinical procedure consisting of an objective measurement with a desktop autorefractor followed by subjective refraction (SR) and (2) with the handheld autorefractor. Agreement between both methods was evaluated using Bland-Altman analysis and by comparing the visual acuity (VA) with trial frames set to the resulting measurements. RESULTS The study was conducted on 54 patients (33.9 ± 14.1 years of age) with a spherical equivalent (M) refraction determined by SR ranging from −7.25 to 4.25 D (mean ± SD, −0.93 ± 1.95 D). Mean differences between the portable autorefractor and SR were 0.09 ± 0.39, −0.06 ± 0.13, and 0.02 ± 0.12 D for M, J0, and J45, respectively. The device agreed within 0.5 D of SR in 87% of the eyes for spherical equivalent power. The average VAs achieved from trial lenses set to the wavefront autorefractor and SR results were 0.02 ± 0.015 and 0.015 ± 0.042 logMAR units, respectively. Visual acuity resulting from correction based on the device was the same as or better than that achieved by SR in 87% of the eyes. CONCLUSIONS This study found excellent agreement between the measurements obtained with the portable autorefractor and the prescriptions based on SR and only small differences between the VA achieved by either method.

Validation of a Clinical Aberrometer Using Pyramidal Wavefront Sensing SIGNIFICANCE Measurement of ocular aberrations is a critical component of many optical corrections. PURPOSE This study examines the accuracy and repeatability of a newly available high-resolution pyramidal wavefront sensor–based aberrometer (Osiris by Costruzione Strumenti Oftalmici, Firenze, Italy). METHODS An engineered model eye and a dilated presbyopic eye were used to assess accuracy and repeatability of aberration measurements after systematic introduction of lower- and higher-order aberrations with calibrated trial lenses (sphere +10.00 to −10.00 D, and astigmatic −4.00 and −2.00 D with axis 180, 90, and 45°) and phase plates (−0.57 to 0.60 μm of Seidel spherical aberration defined over a 6-mm pupil diameter). Osiris aberration measurements were compared with those acquired on a previously calibrated COAS-HD aberrometer for foveal and peripheral optics both with and without multizone dual-focus contact lenses. The impact of simulated axial and lateral misalignment was evaluated. RESULTS Root-mean-square errors for paraxial sphere (corneal plane), cylinder, and axis were, respectively, 0.07, 0.11 D, and 1.8° for the engineered model and 0.15, 0.26 D, and 2.7° for the presbyopic eye. Repeatability estimates (i.e., standard deviation of 10 repeat measures) for the model and presbyopic eyes were 0.026 and 0.039 D for spherical error. Root-mean-square errors of 0.01 and 0.02 μm, respectively, were observed for primary spherical aberration and horizontal coma (model eye). Foveal and peripheral measures of higher- and lower-order aberrations measured with the Osiris closely matched parallel data collected with the COAS-HD aberrometer both with and without dual-focus zonal bifocal contact lenses. Operator errors of focus and alignment introduced changes of 0.018 and 0.02 D/mm in sphere estimates. CONCLUSIONS The newly available clinical pyramidal aberrometer provided accurate and repeatable measures of lower- and higher-order aberrations, even in the challenging but clinically important cases of peripheral retina and multifocal optics.

Assessing the Validity of Measurements of Swept-source and Partial Coherence Interferometry Devices in Cataract Patients SIGNIFICANCE The validity of measurements of OA-2000 (Tomey, Nagoya, Japan), a new swept-source optical coherence tomography–based biometer, was evaluated in comparison with IOLMaster 500 (Carl Zeiss Meditec AG, Jena, Germany) as a reference method for optical biometry in cataract patients. PURPOSE This article compares the validity of measurements between OA-2000 and IOLMaster 500. METHODS In this cross-sectional study, axial length, lens thickness, anterior chamber depth, and keratometry readings were obtained by the OA-2000 and IOLMaster 500. Two measurements were taken by each method. Patients in which any one of the biometry methods could not be performed owing to severity of the cataract were excluded from the study. Repeatability of measurements was presented by coefficient of variation, and Bland-Altman method was used for evaluating the agreement between the two biometers. RESULTS Fifty-eight eyes of 58 cataract patients with mean ± standard deviation age of 61.4 ± 8.3 years were included in this study. Intraclass correlation ranged from 0.898 to 0.901 and showed good to excellent reliability. It was good for keratometry 1 (0.898) and excellent for keratometry 2 (0.992), axial length (0.999), and anterior chamber depth (0.901). Bland-Altman analysis showed good agreement between the swept-source optical coherence tomography and partial coherence interferometry devices for axial length, anterior chamber depth, and mean keratometry, with narrow 95% limits of agreement (−0.09 to 0.1 mm, −0.33 to 0.54 mm, −0.97 to 1.03 D, respectively), and also indicated small mean difference (0.01 for axial length, 0.11 for anterior chamber depth, 0.03 for mean keratometry, respectively) for all comparisons. CONCLUSIONS OA-2000 as a new swept-source optical coherence tomography has an excellent repeatability for measurement of biometric data in cataract patients, comparing with the standard partial coherence interferometry biometer (IOLMaster 500).

Anterior Chamber Angle Evaluation Using Gonioscopy: Consistency and Agreement between Optometrists and Ophthalmologists SIGNIFICANCE In our intermediate-tier glaucoma care clinic, we demonstrate fair to moderate agreement in gonioscopy examination between optometrists and ophthalmologists, but excellent agreement when considering open versus closed angles. We highlight the need for increased consistency in the evaluation and recording of angle status using gonioscopy. PURPOSE The consistency of gonioscopy results obtained by different clinicians is not known but is important in moving toward practice modalities such as telemedicine and collaborative care clinics. The purpose of this study was to evaluate the description and concordance of gonioscopy results among different practitioners. METHODS The medical records of 101 patients seen within a collaborative care glaucoma clinic who had undergone gonioscopic assessment by two clinicians (one optometrist and either one general ophthalmologist [n = 50] or one glaucoma specialist [n = 51]) were reviewed. The gonioscopy records were evaluated for their descriptions of deepest structure seen, trabecular pigmentation, iris configuration, and other features. These were compared between clinicians (optometrist vs. ophthalmologist) and against the final diagnosis. RESULTS Overall, 51.9 and 59.8% of angles were graded identically in terms of deepest visible structure when comparing between optometrist versus general ophthalmologist and optometrist versus glaucoma specialist, respectively. The concordance increased when considering ±1 of the grade (67.4 and 78.5%, respectively), and agreement with the final diagnosis was high (>90%). Variations in angle grading other than naming structures were observed (2.0, 30, and 3.9% for optometrist, general ophthalmologist, and glaucoma specialist, respectively). Most of the time, trabecular pigmentation or iris configuration was not described. CONCLUSIONS Fair to moderate concordance in gonioscopy was achieved between optometrists and ophthalmologists in a collaborative care clinic in which there is consistent feedback and clinical review. To move toward unified medical records and a telemedicine model, improved consistency of record keeping and angle description is required.

Assessing Variability in Reading Performance with the New Greek Standardized Reading Speed Texts (IReST) SIGNIFICANCE This article evaluates the standardized Greek version of the International Reading Speed Texts (IReST) set, which enriches interlanguage comparisons and international clinical studies of reading performance. Moreover, it investigates how specific textual and subject-related characteristics modulate the variability of reading speed across texts and readers. PURPOSE The purpose of this study was to develop a standardized Greek version of the IReST set and investigate how specific textual and subject-related factors modulate the variability of reading speed across texts and readers. METHODS The English IReST texts were translated to Greek and matched for length, content, and linguistic difficulty. The Greek IReSTs were presented at a distance of 40 cm and size of 1 M to assess reading speeds of 25 normally sighted native speakers (age range, 18 to 35 years). The participants read the texts aloud while reading time was measured by stopwatch. Reading performance included measurement of reading speed in three units of analysis. Reading efficiency was assessed using a word-level oral reading task. Statistical analysis included evaluation of subject- and text-related variability, as well as correlations between reading speed and specific textual and subject-related factors. RESULTS The average reading speed between texts was 208 ± 24 words/min, 450 ± 24 syllables/min, and 1049 ± 105 characters/min. Differences between readers accounted for the 76.6%, whereas differences across texts accounted for the 23.4% of the total variability of reading speed. Word length (in syllables per word) and median word frequency showed a statistically significant contribution to the variability of reading speed (r = 0.95 and 0.70, respectively). Reading speed was also statistically correlated with word reading efficiency (r = 0.68). CONCLUSIONS The addition of the Greek version in the IReST language pack is expected to be a valuable tool for clinical practice and research, enriching interlanguage comparisons and international studies of reading performance.

Standardization of Reading Charts: A Review of Recent Developments This review gives an overview of the current status of standardization by statistical evaluation of reading charts. First begun only 20 years ago, the statistical evaluation of reading charts now reflects an increasing clinical and scientific interest in standardized, comparable, and reproducible reading charts. For clinical or research purposes in human subjects, standardization of psychophysical tests and their test items by statistical evaluation is mandatory because it provides experimental control. Initial attempts at reading chart standardization were made by characterizing the test items, either in terms of a selection of unrelated words or in terms of sentences representing a constant number of characters, including spaces. As initiated by the RADNER Reading Charts, standardization of reading charts (and test items) by statistical evaluation has gained increasing clinical and scientific interest in the last two decades and has later also been applied to some of the other modern reading charts. A literature search was performed with respect to reading charts that (a) have been produced in accordance with the recommendations of the International Council of Ophthalmology (geometrical print size progression), (b) have been statistically analyzed, and/or (c) use clearly characterized test items (conceptually and statistically). These reading charts are as follows: the Bailey-Lovie Word Reading Charts, the Colenbrander Cards, the RADNER Reading Charts, the MNREAD Acuity Charts, the Smith-Kettlewell Reading Test (SKread Test), the C-Read Charts, and the Balsam Alabdulkader-Leat (BAL) Chart. The test items of these charts have been characterized either empirically or by statistical analysis and selection. The extent of the statistical evaluation of the reading charts varies. Despite their different methodological approaches, these reading charts represent an advancement that has made possible the useful comparison and reproducible evaluation of near visual performance.

Topical Review: Retinally Induced Aniseikonia SIGNIFICANCE We review retinally induced aniseikonia, an underrecognized condition resulting from common retinal conditions that has a significant effect on quality of life. Optometrists can influence the timing of surgical intervention to mitigate the damage from delaying surgical intervention in patients whose other findings do not meet a surgeon's treatment threshold. Aniseikonia due to optical differences between the eyes occurs in 1 to 3.5% of the population and can hinder the quality of binocular vision. The less noted retinally induced aniseikonia is due to mechanical distortion and displacement of the retinal photoreceptors and occurs with disorders such as epiretinal membrane, reattached retinal detachment, macular hole, and macular edema. Despite that it was first reported in 1950 and its incidence continues to rise in the aging population, many eye care practitioners are unaware of this condition, which can persist or even be exacerbated after treatment as a contributing cause of binocular vision symptoms. The purpose of this report is to allow more eye care practitioners to become familiar with retinally induced aniseikonia. The review of the literature includes demographics and epidemiology, etiology, pathogenesis, diagnosis, results of treatment, prognosis, and case examples.

Topical Review: Effects of Contact Lens Wear on Corneal, Conjunctival, and Lid Margin Sensitivity SIGNIFICANCE Contemporary soft contact lenses do not affect mechanical sensitivity of the cornea, whereas conjunctival sensitivity is increased compared with nonwearers. Orthokeratology lens wear, however, reduces corneal sensitivity. The effects of contact lenses on lid margin sensitivity are unclear, and the link between ocular surface sensitivity and discomfort requires further exploration. Although up to 50% of contact lens wearers experience discomfort with varying severity, impact, and frequency, the relationship between ocular surface sensitivity and ocular surface discomfort experienced during contact lens wear is unclear. The purpose of this review is to examine and summarize the current evidence for the impact of both historical and contemporary contact lens wear on ocular surface sensitivity, the etiology of changes in ocular surface sensitivity, contact lens wear–related factors associated with changes in ocular surface sensitivity, and the relationship between sensitivity and discomfort. Despite minimal effects on mechanical corneal sensitivity with contemporary soft contact lens wear, orthokeratology reduces corneal sensitivity through pressure-related effects. This review addresses the relevance of conjunctival and potentially lid margin sensitivity in tolerance and discomfort with contemporary lens wear and the impact of instrument and stimulus characteristics. Less invasive techniques particularly for lid margin sensitivity measurements are required. Given the potential interactions between a contact lens and the varied types of ocular surface nociceptors, instruments that allow for exploration of cold and chemical sensitivity particularly may better allow the effects of lens wear to be elucidated compared with those that explore high-threshold mechanical sensitivity alone. A better understanding of the relationships between lens wear and ocular surface sensitivity may result in improved management of contact lens discomfort.