Vetenskap 10 16

VETENSKAP # 10–2016 www.optikbranschen.se

Att hantera det du ser

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u är arbetet i full gång. Hösten är här och med den många som upptäcker att synen inte är bra längre. Då passar det bra med ett arbete från magisterutbildningen som handlar om ögonbottens förändringar på äldre personer.

Den andra artikeln ligger som länk och där har choroideas förändring under ackommodation undersökts. Båda två är mycket läsvärda.

Att veta vad som syns vid undersökningar och vad dessa fynd kan orsakas av och hur de ska hanteras är viktigt. Men lika viktigt är det att rätt kunna tolka remissvaren som vi får tillbaka. Ett sådant svar har diskuterats på de sociala medierna senaste tiden, där en del ansett svaret rätt och andra gett uttryck för frustration. Remissen gällde en person med en blödning i retina utan några andra symptom eller visusnedsättning.

Remissvaret från ögonläkaren var, att så länge inga symptom eller visuspåverkan finns behövs inte någon undersökning av bakre pol, men att det kan vara relevant att kontrollera blodtryck och blodsocker. Det svaret är rätt, specialistläkare (ögon) ska arbeta med de ögonsjukdomar som inte primärvården kan ta hand om, hypertoni samt

diabetes vilket bör misstänkas här, utreds av allmänläkare och inte ögonläkare.

Vi optiker är primärvården för ögon tillsammans med allmänläkare. Denna patient ska remitteras till dem och ögonbotten följas upp av oss. Om en optiker inte anser sig kunna ta ansvaret eller ha kunskapen för denna uppföljning bör patienten remitteras till en optikerkollega som har möjligheten, men inte en remiss till specialistvården. Ett kortfattat patientfall rörande detta med positiva remissvar finns att läsa på vetenskapens nätsida.

Med tanke på frågeställningarna enligt ovan så rekommenderas SOFEP–kursen Att skriva remiss, den kommer att erbjudas under våren igen. Dessutom är en ny SOFEP kurs på gång, denna handlar om primärvård, vad vi optiker kan göra och det som ska hanteras av annan primärvård, eller av oss tillsammans. Även SOTA dokumenten, ”Att skriva remiss och Att arbeta med bilddokumentation” som finns på Optikerförbundets intranät innehåller bra information om ovan fråga. CET- frågor finns som vanligt på Optikerförbundets hemsida.

CATARINA ERICSON

n Patientfall: Remiss till vårdcentral vs ögonläkare

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n Artikel 1: Prevalensen av patologiska ögonbottenfynd hos äldre bilförare vid fundusfotografering

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n Artikel 2: Regionala förändringar i choroidal tjocklek associerade med ackommodation

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Catarina Ericson är OPTIK:s vetenskapsredaktör. Hon är MSc i Klinisk Optometri och Leg Optiker. e-post: catarina@c-optik.se

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PATIENTFALL:

Remiss till vårdcentral vs ögonläkare Remiss till vårdcentral vs ögonläkare – patientfall Refraktionsförändring är för ålder normal och tas inte upp i denna beskrivning.

2014 78- årig dam kommer för synundersökning då det börjar bli svårare att läsa. Fynd att uppmärksamma är – Fundusundersökning visar en A/V-kvot på 2/4 samt en liten knuta utan ökad pigmentering på höger nedre ögonlock. Enligt patienten har denna knuta funnits i många år och är kontrollerad av ögonläkare.

Bedömning/åtgärd: Knuta fotograferas och dokumenteras, kallas för ny kontroll om 1 år, vid förändring får patient höra av sig tidigare.

Blodtryck ska kontrolleras med hänsyn till A/V-kvot, då detta inte är gjort på länge. Patient meddelar sedan efter besök på vårdcentral (VC) resultatet hit. Kallas om 1 år om inget annat uppkommer.

Telefonsamtal 2 veckor senare då patient varit på VC. Blodtryck är förhöjt och ska utredas.

2015 Kommer för ny synundersökning. Varit kontinuerligt på VC för kontroll av blodtryck, utfört dygnsmätning som är något förhöjt men har inte någon medicinering.

Idag är A/V- kvot ¼ med snirkliga kärl. Knutan på ögonlock, svagt pigmenterad och även sårig, varit så i 2 månader.

Bedömning/åtgärd: Skickar remiss till vårdcentral med uppgifter om kärlförändringar som skett senaste året. Önskar remissvar.

Skickar remiss till ögonläkare för kontroll av pigmenterad, sårig knuta, Basiliom? Önskar bedömning, om möjligt åtgärd samt remissvar Informerar att remiss är skickad till VC för kontroll av blodtryck pga hypertona kärl.

Remissvar från VC, allmänläkare: 24h mätning är gjord med medelvärde dagtid 133/93 samt natt 133/90 med förhöjd hjärtfrekvens, medel 105. Då ögonbottenförändringar syns, så sätts betablockare in för att kapa topparna som ibland uppkommer.

Remissvar från ögonläkare: Borttag av 3*53mm hud, misstänkt basalcellscancer material skickas för kontroll.

Kärl är misstänkt hyperona, tacksamt att ni skickat detta till allmänläkare.

KOMMENTARER Här skickas remiss till den vårdinstans som ska handha problemet. Att informera ögonläkaren att remiss är skriven till VC för misstänkt hypertoni gör att de inte behöver göra detta om blodkärlen kontrolleras. I detta fall undersöktes kärlen, kanske för att kommentaren, fanns men det var uppskattat.

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Redaktörens kommentar:

Introduktionsdelen ger en bra information om de olika tillstånden som undersöks. Metoddelen visar på indelningen av dessa som ligger till grund för resultatet som är intressant att läsa. Diskussionsdelen leder till eftertanke.

Prevalensen av patologiska ögonbottenfynd hos äldre bilförare vid fundusfotografering PREVALENCE OF PATHOLOGICAL FINDINGS IN OLDER DRIVERS USING FUNDUS PHOTOGRAPHY 1.0 INTRODUCTION The expected lifetime increases over the world and the older population is growing, at the same time people live longer and have better health in general. The increasing number of older people will lead to an increased number of individuals suffering from age-related diseases.

This will cause a higher pressure on the health care system due to a bigger population of older people in comparison to the number of people being able to work and pay taxes. Vision is an important sense to stay intact and it is essential to maintain a vision-related quality of life and that is desirable to be preserved for as long as possible (Voleti & Hubschman, 2013).

The most common eye diseases found in a older population is cataract, age-related macular degeneration (AMD), glaucoma and diabetic retinopathy (Quillen, 1999).

According to Laitinen et al. (2010), the prevalence for subject over 65 years were 34.0% cataract, 13.0% glaucoma, 12.0% age-related maculopathy (ARM) and 2.0% diabetic retinopathy (DR). Retinal diseases are the leading cause of visual impairment in older population (Nowak et al., 2015).

1.1 Cataract In Sydney, Australia, a ten-year follow-up study was performed to evaluate the prevalence and progression of age-related cataract and cataract surgery (Kanthan et al., 2008). The prevalence was 36.0% for nuclear cataract, 28.0% for cortical cataract and 9.1% for pos-

terior subcapsular cataract. The mean age at cataract surgery was 75.8 year and was performed in 17.8% of the subjects. The prevalence for each type of cataract and cataract surgery was associated with increasing age. In the study by Kanthan et al. (2008), 72.0% of the participants were affected by cataract or had cataract surgery over the ten-year follow-up period.

1.2 Age-related macular degeneration In Reykjavik, Iceland, Jonasson et al. (2011) found that the prevalence of early AMD was 12.4% for those aged 66 to 74 years and 36.0% for those aged 85 years. The prevalence of exudative AMD was 3.3%. The highest prevalence of late exudative AMD was among the participants aged 85 years; 11.4%. The conclusion was that people aged 85 years have a ten-fold higher prevalence of late AMD than those aged 70 to 74 years.

Fisher et al. (2015) performed a follow-up study on the correlation between AMD and mortality. The conclusion presented that it was a correlation between mortality and late AMD. Late AMD was not the factor of death but associated with other diseases.

1.3 Glaucoma Heijl et al. (2013) performed a trial-screening study to evaluate the prevalence of glaucoma. A total of 1.23% (406 subjects) was identified with previously undetected glaucoma. Prevalence increased with age, from 0.55% at 55 to 59 years to 2.73% at 75 to 79 years. The extent of visual field loss was similar in all age groups from 60 years and older. Most eyes had early (35.0%) or moderate (31.0%) glaucomatous visual field defects, but 134 subjects (33.0%) had advanced visual field loss in at

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least one eye. The conclusion was that the prevalence of undetected glaucoma increased with age, whereas disease severity did not increase in subjects older than 60 years of age.

The Ocular Hypertension Treatment Study (OHTS) illustrated that the mean vertical cup-disc ratio for the subjects who developed primary open angle glaucoma (POAG) during the study was 0.48 (±0.20) and 0.38 (±0.17) for the subjects not developing POAG (Gordon et al., 2002). Although, a study by Garway-Heath et al. (1998) demonstrated that the ability of the cup-disc ratio to distinguish between normal and early glaucomatous optic nerve head was limited.

Leske et al. (2003) performed a study on glaucoma progression and illustrated that optic disc hemorrhage was strongly related to glaucoma progression.

1.4 Diabetic retinopathy A screening-study performed in Wales, United Kingdom (Thomas et al., 2015), evaluated the prevalence and severity of DR among subjects with diabetes. The prevalence of any DR in the group of diabetes type 1, was 56.0% and sight-threatening DR was 11.2%, and in diabetes type 2 the prevalence was 30.3% of any DR and 2.9% of the sight-threatening DR. 1.5 Epiretinal membrane Epiretinal membrane (ERM) is a sheet-like fibrocellular structure that develops at the surface of the retina.

The membrane can emerge due to idiopatic or secondary causes and leads to visual symptoms like blurring, metamorphopsia and retinal wrinkling. The secondary causes include origin after detachment, surgery or trauma (Kanski & Brad, 2007). ERM is a relatively common condition in elderly population and increases with age. The prevalence is 6.0% and similar in males and females (McCarty et al., 2005).

1.6 Driving requirements In Sweden there is a strong debate regarding whether the driving license should be renewed at a particular age. If a renewal were to be mandatory one could argue which tests that should be included in a test battery, aiming to reveal suitability for driving.

The vision requirement for driving in Sweden is visual acuity 0.5 binocularly. The vision field has to spread 120 degrees horizontal with at least 50 degrees at both sides and spread at least 20 degrees in both directions vertical (Transportstyrelsen, TSFS 2010:125).

A study initiated by Statens Väg- och Transportforskningsinstitut (VTI – The governmental Road and Transport-research Institute) aims is to better understand the experience of older drivers use of vision and/or hearing aids. The purpose of the study is to determine the relationships between self reported hearing and vision

function, clinical tested hearing, vision and cognitive function, and perceived driving performances.

2.0 PURPOSE To investigate the prevalence of pathological findings in older drivers using fundus photography, in a Swedish normal population aged 60 years and older.

To investigate the importance of additional medical examination associated with renewal of driving license for drivers over 60 years of age.

3.0 MATERIAL AND METHODS The data was collected from a project established by VTI, where 105 subjects (59 women and 46 men) aged 60 and older, were included. The mean age was 69.5 years with a range of 60 to 87. The aim of the VTI-project was to evaluate if there is any difference in driving behavior between population with or without spectacles and/ or hearing aid. Since the subjects were already in the clinic, a fundus photograph was taken and analyzed as part of this smaller investigation.

A macula centered, 45 degree field photo was captured in both eyes in all subjects with the fundus camera, Canon CR2Plus. No mydriatics were used. Visual acuity was measured with high contrast letter charts designed according to EDTRS using a test distance of 4 meters and the subjects were wearing their current correction for driving. All measurements was performed at the facilities of Karolinska Institutet, Unit of Optometry at the Departement of Clinical Neuroscience, S:t Erik Eye Hospital, Stockholm.

3.1 Survey The subjects answered a survey about symptoms, heredity and previous visits to ophthalmologists. Additional survey questions: Have you visit your optometrist within 3 years? Yes/No Have you visit an ophthalmologist within 3 years? Yes/ No. Yes, for what reason?

Have you done a cataract surgery? Yes/No. Do you have a disease, eye related or other? Yes/No. Yes, of which kind?

Is there heredity within close family (mother, father, and sibling) for an eye disease? Yes/No. Yes, of which kind?

3.2 Categories To grade the photographs clinically, the findings were divided into seven categories. Since some of the eyes had several finding they appear in more than one category.

Non assessable Includes the photos that were impossible to assess according to poor photograph quality.

No pathology

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Includes the findings that were not classified as pathological, such as congenital findings (e.g. myelin at the optic nerve head) and mild age-related changes which did not require extended examination (e.g. few hard drusen). A few hard drusen is not considered to be a risk factor for the development of age-related maculopathy (Sarks et al., 1999) Maculopathy - visual acuity ≥0.5 Macular changes with mild or no effect on visual acuity, such as early age-related macular changes, small amount of hard drusen, epiretinal membrane, pigmental distorsion. Drusen <63µm in diameter was classified as hard drusen and can be related to half a retinal vein width (125µm)(Sarks et al., 1994).

Visual acuity was used as an complement to specify the severity of the pathological findings and eyes with visual acuity ≥0.5 was included in this category.

Maculopathy - visual acuity <0.5 Macular changes with moderate or severe effect on visual acuity, such as macular degeneration, hard and/or soft drusen, epiretinal membrane, pigmental distorsion, atrophy. Drusen >63µm in diameter was classified as soft drusen which is related to a half to one retinal vein width (125µm) (Sarks et al., 1994).

As in the category above, visual acuity was used as an complement to specify the severity of the pathological findings and eyes with visual acuity <0.5 was included in this category.

Hypertonic retina Hypertension is relatively frequent in Sweden and can be estimated to 1.8 million people (SBU, 2004). Even if this is a generalized disease, there are changes that can be found at the retina e.g. arteriosclerosis, arteriovenous nicking, diabetic retinopathy. Eyes with vascular involvement were included in this group.

Glaucoma suspects Includes the retinal risk indicators of glaucoma, such as optic disc hemorrhage and excavated cup-disc ratio. In this study, vertical cup-disc ratio ≥0.5 was considered as glaucoma suspects. The vertical cup-disc ratio was measured using the fundus photo.

A fundus photo is not a complete evaluation of glaucoma suspects. In this study, only fundus photo and visual acuity was collected of clinical value. No consideration was taken to the intraocular pressure (IOP), visual field or corneal thickness (Gordon et al., 2002).

Peripheral findings Moderate or severe changes found outside the macula in the peripheral fundus e.g. hard drusen, atrophy.

3.3 ETHICS All subjects answered an informed consent where they agreed to be involved in the study and that all their data will be used. All subjects are anonymous and the informed consent is approved by the ethics committee.

The study was conducted according to the Declaration of Helsinki.

3.4 Statistic analyze To make a statistical analysis of the data, GraphPad InStat® version 3 were used. Unpaired t-test was performed to analyze the data of visual acuity. Fundus photo were graded clinically and data was not further analyzed.

4.0 RESULTS In this study all eyes were assessed separately, therefore a total of 210 photos were evaluated. Thirty-one photos (14.8%) were impossible to assess due to poor photograph quality and 84 photos (40.0%) were classified as having poor quality but still assessable. Mainly, photos of left eyes were of poor quality than right eyes (47.6% and 30.5% respectively). Since this study investigates the importance of renewal of driving license for older drivers, visual acuity below 0.5 is considered as reduced vision due to Swedish ophthalmological requirements for driving.

4.1 Prevalence Figure 1 illustrates that 31 eyes (14.8%) were not assessable, 102 (48.6%) had no pathology, 30 (14.3%) had maculopathy with visual acuity ≥0.5, 3 (1.4%) had maculopathy with visual acuity <0.5, 20 (9.5%) had hypertonic retina, 10 (4.8%) were glaucoma suspects and 18 (8.6%) had peripheral findings. Accordingly, 48.6% is shown with no pathology and 38.6% had some kind of pathology in the fundus.

All categories included, 21 eyes (10.0%) had visual acuity <0.5. All subjects had visual acuity binocularly ≥0.5 and therefore pass the ophthalmological requirements for driving.

Peripapillary atrophy was present in 101 eyes (48.1%)

Figure 1.

Illustrates the number of eyes in all 7 categories.

Four of the eyes were divided into 2 categories and therefore appear 2 times in the figure.

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whence 50 right eyes (47.6%) and 51 left eyes (48.6%).

In the survey, 19 subjects (18.1%) answered that they have had a cataract surgery performed. Eight subjects (7.6%) answered that they are diagnosed with hypertension or diabetes and 2 of them were categorized as hypertonic retina regarding the findings in the retina.

The prevalence of DR was 1.9% (2 subjects). Additionally, 2 other subjects said to be diagnosed with diabetes when answering the survey, but did not show signs of DR in the fundus.

The prevalence of ERM in this study was 3.3% (7 eyes).

Figure 2. Illustrating the mean and range in visual acuity between sample A (no pathology) and sample B (maculopathy - visual acuity ≥0.5 and maculopathy – visual acuity <0.5).

visual acuity <1.0 and 3 of them (12.5%) had not been to an optometrist within 3 years.

An unpaired t-test was performed and the difference in visual acuity between the category no pathology and both categories of maculopathy was significant (p=0.0321).

The mean visual acuity of sample A was 0.9 (±0.34 SD) and 0.7 (±0.32 SD) of sample B (Figure 2). Ten eyes in sample A (9.8%) and 3 eyes in sample B (9.1%), had visual acuity <0.5.

Among the subjects, 128 (61.0 %) was wearing spectacles when driving. An unpaired t-test was performed to evaluate the difference in visual acuity between the subjects wearing spectacles and the subjects not wearing spectacles when driving. The difference was highly significant (p < 0.0001).

The mean visual acuity of sample A was 0.7 (±0.34 SD) and 0.9 (±0.31 SD) of sample B (Figure 3).

4.3 Referrals and heredity During the study, 5 subjects (4.8%) had to be referred to ophthalmologists due to the retinal findings. The retinal pathology found was exudative AMD, suspected lamellar macular hole, suspected glaucoma with optic disc hemorrhage and 2 cases of diabetic retinopathy with hemorrhages and neovascularization. Additionally, 22 subjects (21.0%) were recommended to do an extended eye examination within a near future. This recommendation was made when age-related findings were shown in the fundus and additional measurements (e.g. intraocular pressure, visual field) and medical history would benefit the assessment.

Table 1. Retinal findings among the 22 subjects recommended doing an extended eye examination.

Figure 3. Illustrating the mean and range in visual acuity between sample A (no spectacle correction when driving) and sample B (spectacle-wearer when driving).

4.2 Visual acuity In the category no pathology, 55 eyes (53.9%) had visual acuity <1.0 and 18 of them (32.7%) had not been to an optometrist within 3 years. This is the group where there is no medical obstacle in the retina for visual acuity to be 1.0.

In the category maculopathy - visual acuity ≥0.5 and maculopathy - visual acuity <0.5, 24 eyes (72.7%) had

The most frequent cause was glaucoma suspects and maculopathy which 9 subjects (40.9%) had respectively.

Three subjects (13.6%) were recommended to contact a general practitioner to examine their blood pressure regarding the findings of hypertonic retina. Additionally, 1 subject (4.5%) had moderate amount of hard drusen in the periphery.

In the survey, 16 subjects (15.2%) answered that they have an eye disease-related heredity. Four subjects (3.8%) have heredity for AMD, 6 subjects (5.7%) for glaucoma and 11 subjects (10.5%) stated cataract as their heredity.

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Table 2. Illustrating the heredity and distribution among the 3 causes given by subjects in the survey. Five of the subjects said to have 2 heredities and therefore appear in 2 groups.

In 5 of the cases in table 2 (31.3%), heredity and the findings made in the fundus photo are related. Three of them were related to AMD, where a few hard drusen was found and 2 of them were related to glaucoma suspects where we found excavated cup-disc ratio or optic disc hemorrhage. In the cases of AMD, none of the subjects were divided into any of the 2 categories of maculopathy. Although, a few hard drusen cannot be related to AMD and a prediction if AMD will develop in the future is impossible in this study.

5.0 DISCUSSION During the last few years, fundus cameras have become more frequently used within optometry settings. The costumers are also offered extended eye examination including for example fundus photography to support detection pathological findings at an earlier stage. For example, all Specsavers Sweden AB optometry settings are equipped with fundus cameras since 2015.

The vision is important, especially when driving. Even early stages of eye diseases can affect the drivers e.g. cataract affecting the contrast (night vision), glaucoma affecting the visual field and AMD affecting visual acuity.

In this study, the prevalence of the diseases referred to in the introduction, are at a lower percentage. The reason could be that these studies are follow-up studies or have recruited subjects with a specific disease.

The fact that 31 photos were not assessable illustrates that even if the clinic has a fundus camera, there is no guarantee that the photos will be of value. Accordingly, 84 photos were of poor quality yet assessable which can be related to miotic pupils and/or cataract. The reason for more frequent photos of left eyes with poor quality is that the right eye was photographed first and there was not enough time waiting until the left pupil was dilated to its initial size. Optimal conditions would have been to perform the fundus photo of dilated pupils, however this study wanted to illustrate the reality of the optometry occupation in Sweden, waiting to obtain access of mydriatics.

Examine the fundus is most important in an older population and their pupils are usually miotic, which illustrates the importance of access to the mydriatics.

With the help of mydriatics, optometrist could easier examine the fundus and therefore write adequate

referrals. This would also reduce the incidence of unnecessary referrals and therefore assist the healthcare system. Some of the eye diseases e.g. dry AMD do not require treatment by an ophthalmologist since there are none available at the time (Zając-Pytrus et al., 2014). In that case, the optometrist can perform the follow-ups and the information to the patient without involving the healthcare. If the optometrists have access to mydriatics, fundus camera and/or 90-lens, there are great possibilities that adequate assessment of the conditions is made: if it should be referred or not and the urgency required.

Eight subjects answered in the survey that they are diagnosed with hypertension or diabetes. In 2 of these 8 subjects, this condition was also seen in the retina when the fundus photo was assessed. Although, we do know that 1 subjects diagnosed with DR did not state that in the survey. This exemplifies the difficulty of receiving the correct answers in a survey answered by the subjects unaccompanied.

In this study, 12 subjects (20 eyes) were divided into the category of hypertonic retina. Two of them (16.7%) correlate with the answers in the survey demonstrating: 2 of the 12 subjects divided into the category of hypertonic retina had a confirmed hypertonic disease that we could see in the fundus. The 10 remaining subjects (83.3%) can be explained by (1) they did not give an adequate answer in the survey or (2) their hypertonic disease is undetected. This illustrates that by examine the fundus, optometrist could contribute to the healthcare system and detect signs of hypertonia in patients unaware of their condition. Vascular changes in the retina predict cardiovascular occurrence to some extent (Flammer et al., 2013). According to Klein et al. (1997) hypertension is related to an increased incidence of retinopathy.

There was a statistical significant difference in visual acuity between the categories no pathology and maculopathy (visual acuity <0.5 and visual acuity ≥0.5) (figure 2).

A greater amount of subjects in the group of maculopathy, had been to an optometrist within 3 year which leads to the theory that patients with pathological findings visit their optometrist more frequently, given that the patient has symptoms. As many as 55 eyes (53.9%) with no pathology had visual acuity below 1.0 and 18 of them (32.7%) had not visited their optometrist within 3 years. This illustrates that theoretically ≥18 of the 55 subject might have the capacity for better vision with new spectacles.

This is the group where there is no medical obstacle visible for not obtaining visual acuity 1.0. Ten eyes (9.8%) with no pathology had visual acuity <0.50 which could not be explained by the findings in the retina. A majority of the 10 eyes had dim fundus photos indicating cataract.

Refraction was not included in this study and therefore this question cannot be answered properly.

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If an extended test battery for renewal of driving license were to be mandatory, there is a debate of which tests that should be included. To reduce vision-related traffic accidents, additional medical examination should be considered. Visual acuity and visual field require to be examined as before. Confrontation visual field is a simple method to screen for visual field defects, however it is a rough measurement and depend on the technique of the examiner. Although, it does not require expensive equipment. As a complement, a measurement of the IOP would be preferred to help exclude suspected glaucoma.

With the use of a non-contact tonometer (NCT), it is a simple and quick method to measure the IOP and it gives complementary information to fundus assessment and visual field mainly.

The visual acuity should be measured in both high and low contrast for a better understanding of the vision in reality. A patient with visual acuity 0.5 does not have that when driving at night or in the rain. Cataract, as mentioned before, is also a great cause of reduced visual acuity in low contrast.

Further, an evaluation of the fundus (fundus photo, 90-lens or ophthalmoscopy) would be preferred considering the age group. The prevalence of impaired vision increases with age (Klaver et al., 1990). All eye diseases do not give symptoms at an early stage and a mandatory examination of the retina gives much information about the health of the eye. Amsler grid is a complementary measurement to evaluate the macular involvement and how affected the macula is. Additionally, it evaluates the central visual field within 10 degrees.

If one of the tests does not get approved, the patients may need to be referred to ophthalmologists or perform the renewal within a shorter time frame. Of course, visual acuity and visual field does always need to be within the requirements for driving. Although, this study did not perform enough tests to decide if a renewal of driving license in older drivers should be implemented.

A community based screening for glaucoma is not cost effective out of a societal perspective (Heijl et al., 2013). However, it is valuable for the individual since the prognosis will benefit from early detection and accurate treatment (Jones et al., 1990) since glaucoma is a relatively asymptomatic disease in its initial phase (Grødum et al., 2002). This is an opportunity for optometrists to contribute and the glaucoma screening could be offered by optometrists instead. Gordon et al. (2002) illustrated that measuring IOP, cup disc ratio and corneal thickness will be a good predictor of the individual’s risk of developing POAG and as Heijl et al. (2013) further illustrated, assessing photos of the optic nerve head is sensitive for glaucoma screening.

This study illustrates what an optometrist can expect to find when examine their patients. By the age of 60+ in a normal population, 38.57% present some kind of

pathology or suspected pathology. Although, 5 of them required referral and 22 of them were recommended to do an extended eye examination within near future regarding the findings requiring further testing before adequate treatment could be prescribed.

Almost half of all the eyes (48.1%) present peripapillary atrophy which illustrates that it is a common finding, although it has been noted as a risk indicator for glaucoma. Peripapillary atrophy is significantly larger in glaucomatous eyes than in normal eyes (Jonas & Naumann, 1989).

One advantage of fundus photo is that it is a simple method to follow the health of the eye and the progression. Photos can be set against one another and comparison can easily be made. Communications can easier appear between optometrists or optometrists and ophthalmologists.

6.0 CONCLUSION In 38.6% of all photos, some kind of pathology in the retina was present despite normal visual acuity. The fundus should be examined regularly in all patients over 60 years of age due to early detection of the potential vision threatening eye conditions that would benefit from early detection. Despite the results, this study does not provide any proofs of that the number of accidents would be reduced if fundus examination were to be added to an examination related to renewal of the driving license.

7.0 ERRORS Not measuring subjects refraction and therefore not receiving their best visual acuity.

Recruiting subjects through advertisement may attract people with vision above average. If this study would bring a fundus camera to a pensioner association or screening on the street, the result may differ.

Only measuring the visual acuity with current correction (spectacles or not) and fundus photo. Medical history and additional measurements e.g. IOP, refraction, visual field would have complemented the assessment.

Not waiting enough time between photographing right and left eye to let the left pupil dilate to its initial size.

Not performing the survey together with the subjects.

REFERENCES Fisher, D. E., Jonasson, F., Eiriksdottir, G., Sigurdsson, S., Klein, R., Launer, L. J., Gudnason, V., & Cotch, M. F. (2015). Age-Related Macular Degeneration and Mortality in Community-Dwelling Elders: The Age, Gene/Environment Susceptibility Reykjavik Study. Ophthalmology, 122(2), 382-390.

Flammer, J., Konieczka, K., Bruno, R. M., Virdis, A., Flammer, A. J., & Taddei, S. (2013). The eye and the heart. European heart journal, 34(17), 1270-1278.

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Garway-Heath, D. F., Ruben, S. T., Viswanathan, A., & Hitchings, R. A. (1998). Vertical cup/disc ratio in relation to optic disc size: its value in the assessment of the glaucoma suspect. British journal of ophthalmology, 82(10), 1118-1124.

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10 OPTIK VETENSKAP # 10–2016 n

rch emiologic Resea Clinical and Epid

ssociated With A ss e n k ic h T l a es in Choroid Regional Chang Accommodation

-Caneiro and David Alonso , ns lli Co J. el ha A. Read, Mic logy, iversity of Techno an-Pieterse, Scott , Queensland Un ce en Emily C. Woodm Sci ion Vis etr y and l of Optom Laborator y, Schoo d Visual Optics an ns Le ct nta Co land, Australia Brisbane, Queens

hT) across the idal thickness (C occurring in choro tical coherence s op ge an ng ch agi im the e pth cteriz ed-de PURPOSE. To chara g accommodation using enhanc Emily C. Woodrior pole durin Correspondence: ste Vipo and s Len ct ocular nta ). man-Pieterse, Co res of ChT and tomography (OCT tor y, School of years) had measu li, with the Spectralis 2 6 21 sual Optics Labora age ion Science, participants (mean n to 0, 3, and 6 diopter (D) stimu th Optometr y and Vis ty of TechnoloMETHODS. Forty s mounted on bo rsi mirror system wa ring accommodatio du en tak Queensland Unive try ia me external fixation tor tometer and cold bio op Vic an l d da ck, we Ba Blo A vie O . , ts ter 56 jec biome gy, Room B5 llection while sub OCT and Lenstar Grove 4059, Brismeasurement co Park Road, Kelvin ments, allowing s. tru nd ins ma de ; e alia tiv da str 6 D bane, Au accommo mmodation to the 01). du.au. target at var ying ing during acco e.woodman@qut.e nn 0.0 < thi (P nt s ca ion nifi reg id exhibited sig ) and parafoveal s 15, 2015 Submitted: April RESULTS. The choro veal (mean change, �5 6 7 lm the largest change t 27, 2015 l meridian, with subfo ). ea 01 th ov bo 0.0 raf in < pa (P lus by s Accepted: Augus d mu ian rie sti ad these changes va (�8 6 8 lm) merid n-Pieterse EC, Re The magnitude of (�9 6 12 lm) and inferotemporal ge, þ5 6 11 lm at 3 D, þ14 6 13 Citation: Woodma neiro D. ral an -Ca ch po n nso tem ea Alo , (m the MJ in s on th the choroidal seen SA, Collin with accommodati ely associated wi in choroidal thickial length increased changes were weakly negativ Regional changes Ax . ion dat mo om h acc , and these ness associated wit lm at 6 D) 6 D < 0.05). ol Vis Sci. Invest Ophthalm observed at the s (r2 ¼ 0.114, P ge / an 167 ch 0.1 I:1 DO eal 22. the choroid was ov of raf pa ing ral nn po thi t 2015;56:6414–64 poral and inferotem al variation in all, but significan iovs.15-17102 ion CONCLUSIONS. A sm nd, which was greatest in the tem reg e Th ea. fov ma m the e g eccentricity fro accommodation de ular smooth muscl sed with increasin n of the nonvasc choroid, and increa ing corresponds to the distributio potential mechanism by which the nn the parafoveal thi ich may implicate these cells as the wh within the uvea, raphy g accommodation. coherence tomog choroid thins durin tive error, optical n, myopia, refrac tio da mo om acc id, Keywords: choro 24 tion.19– pany accommoda have ses in AL to accom we , rea R) inc LC t (O can y nifi etr sig tom al t coherence refl ec the major structur small but significan Using optical low length (AL) are e evidence of a n, gression of som tio pro da ed d mo ort an lterations in axial om rep nt y acc me during previousl porting rlying the develop subfoveal choroid with the observed axial change unde also evidence sup thinning of the 1–3 ; however, there is lopassociated ve ly de ive or or gat err err ne e e ly tiv tiv ak rac ref in refrac which was we of the choroid 23 ucing refractive r previous an involvement perimentally ind elongation. assess ChT in ou ) hT (C 4–9 Animal studies ex ss ne ck thi use of OLCR to l T requires ida the Ch r, oro ment. of ve ch n we in tio Ho s na ge mi s rapid chan wth change n, since the deter gro tio subjects ita e of ey lim % a error show that m 63 s in ter wa 6,7 r dy ble stu e the longe hyperopia. and was only possi measurements only d t, an en ia gm op jud appear to preced my e tiv of se subjec development ed by a e. Additionally, the associated with the ment is induced, it is characteriz on at a sin gle with this techniqu subfoveal locati ses in velop e rea de th inc ia at m op T ter my r Ch en ge lon Wh ted ich provided no en by wh res ed ]), rep low [D r fol l pte ing ida dio nn is induced, choro tion demand (4 in Ch T with ia da rapid choroidal thi mo rop ns pe tio om hy ria acc va en al nt ereas wh wth occurs. Rece 5 magnitude about the reg ion gro n e the eye growth, wh tio ey n of ee ma or tw ng be inf wi ip ed by a slo or the relationsh s8–11 and children nd. n, ult ma tio ad thickening follow da de th n mo bo tio om da in s acc mo man studie o appear to e and the accom e of cross-sectional hu olution techniqu choroidal respons ChT changes als ns, with a res of m r he ter r hig ge the lon use tter ma be hu we a in dy, e nt stu vid indicate that me s pro thi In tive error develop raphy (OCT) to d myopia. og an mo tom AL om ce acc sed ren th he rea accompany refrac wi inc optical co refl ect associated with changes associated T also allows anges in ChT may thinner choroid ding of the ChT OC ch , an t rst ore tha de st erm un ge rth r sug Fu data ocula d 6 D demands. sterior pole with changes in Collectively, these dation at 0, 3, an ChT across the po signals associated ional changes in underlying reg nt. ism one of the early of me an res ch lop asu ve me de me tive error ater insight into the ar work an d ne gre e subfoveal n vid ee gle growth and refrac tw pro sin y be a ma k t t jus tha oposed lin than examining d the way in r ensively ine he rat am reh Due to th e pr , ex mp ge co ve an ha to ch s the 12–17 numerous studie t therefore aimed ommodaen acc g rim ge of rin pe ran ex du a is ge myopia, Th to an . ch e location terior ular parameters al Ch T res pons nted changes in an ed which various oc riz e th e reg ion me cte cu ara do ch ll we the 24 with report tion.18– Along 18 ent studies have 6414 a number of rec eye biometrics, Inc.

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Ophthalmology, earch in Vision and Association for Res Copyright 2015 The 783 2-5 155 g j ISSN: iovs.ar vojournals.or

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Redaktörens kommentar:

I bakgrunden ges bra förklaringar till hur de olika sakerna fungerar.

Resultat och diskussiondelarna är mycket intressanta.

Regionala förändringar i choroidal tjocklek associerade med ackommodation Författare: Emily C. Woodman-Pieterse, Scott A. Read, Michael J. Collins, and David Alonso-Caneiro Sammanfattning Catarina Ericson Syftet var att karakterisera de förändringar som sker i choroidal tjocklek (CHT) över den bakre polen under ackommodation med optisk koherens tomografi (OCT).

Fyrtio deltagare kontrollerades för CHT, okulär biometri togs under 0,3 och 6D-ackommodation, med Spectralis OCT och Lenstar biometer.

Choroidea uppvisade väsentlig förtunning under ackommodation med 6 D-wstimuli både subfoveala och parafoveala delar (P <0,001). Omfattningen av

dessa förändringar varierade parafoveal meridian, med de största förändringarna i den temporala och inferotemporala meridianerna (P <0,001). Axiell längd ökade under ackommodation och dessa förändringar svagt negativt samband med den choroidala förändringen.

En liten, men väsentlig förtunning av Choroidea observerades vid 6 D-ackommodation, som var störst i den temporala och inferotemporala parafoveala Choroidea, och ökade med ökande excentricitet från fovea. Den regionala variationen i parafoveal förtunning motsvarar fördelningen av den icke-vaskulära glatta muskulatur inuti uvea, vilket kan implicerar dessa celler som den potentiella mekanismen med vilken choroidea tunnas ut under ackommodation.

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