LOW VISION DEVICES FOR MACULAR DEGENERATION 1

Low Vision Devices for Age-Related Macular Degeneration: A Systematic Review

Anne Macnamara, BPsy(Hons),1 Celia S. Chen, PhD,2 Andrew Davies, BASc,3 Charlotte Sloan,1 &

Tobias Loetscher, PhD,1

1 Cognitive Ageing & Impairment Neurosciences Laboratory, UniSA Justice & Society, University of South

Australia, Adelaide, SA, Australia

2 College of Medicine and Public Health, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia

3 Royal Society for the Blind, Adelaide, SA, Australia

Corresponding author.

Anne Macnamara

Email: [email protected]

Postal address: Campus Central – Magill, University of South Australia, St Bernards Road, Magill SA 5072

LOW VISION DEVICES FOR MACULAR DEGENERATION 2

Abstract

Significance: Age-related macular degeneration (AMD) is a degenerative condition impacting central vision. Evaluating the effectiveness of low vision devices provides empirical evidence on how devices can overcome deficits caused by AMD and facilitates discussion on future improvements to vision enhancement technology.

Methods: A systematic review of the literature was conducted on the use of low vision devices in

AMD populations. Relevant peer-reviewed research articles from six databases were screened.

Results: The findings of thirty-five studies revealed a significant impact of low vision devices leading to improvements in visual acuity, reading performance, facial recognition, and more. While the studies were generally found to have a moderate risk of bias, a GRADE assessment of the evidence suggests that the general certainty of the evidence was low-moderate.

Conclusions: A positive effect of low vision devices was found for visual acuity, reading performance, facial recognition, and more. Simple low vision devices (e.g. magnifiers) appear to currently have greater preferential support than newer, visual enhancement technology (e.g. head mounted devices). Factors influencing this were discussed relative to low vision device features, the

AMD demographic, and financial considerations. This is compounded by a lack of studies examining newer technologies in AMD populations, which future research should address. Moreover, given the presence of bias across the studies, heighted by limited controlled experiments, there may be inadequate confidence in the results. So, even though low vision devices are reported to be a valuable asset to AMD populations, more rigorous research is required to draw conclusive evidence.

Keywords: Low vision devices, age-related macular degeneration, visual impairment, quality of life. rehabilitation

LOW VISION DEVICES FOR MACULAR DEGENERATION 3

Affecting approximately 200 million people globally, age-related macular degeneration (AMD) leads to visual impairment and can cause blindness.1,2 The burden of vision impairments is significant, with direct and indirect economical costs that amount to billions of dollars associated with AMD within Australia alone.3,4 Given the scope of AMD, investigating strategies and interventions to effectively manage it is of high importance to the visual impairment community, especially with an increasingly aging population.

Consequences of Age-Related Macular Degeneration

AMD is a progressive degenerative eye condition that is characterized by the deterioration of the retina. Early AMD is caused by subretinal drusen, small yellow or white lipid products. As it evolves into the later stages, choroidal neovascularization may occur, in which blood vessels grow under and leak fluid and blood into the macula.5 The visual symptoms of AMD manifest in a variety of ways, leading to difficulties in areas such as reading, computer use, driving, and recognizing faces.6,7

Severe AMD can make reading a single word almost impossible without vision enhancement.8

Impaired abilities to perceive faces and recognize emotions are linked to reduced quality of life and social engagement, because people with AMD lose confidence in detecting social nuances and become concerned about offending their acquaintances.7 There is also a heightened risk of falls and injury due to declining hazard detection.9 These factors, and more, can contribute to increased depression and anxiety;10,11 as well as an overall effect on all manner of physical, social and psychological domains.12,13

Managing Age-Related Macular Degeneration

The management of AMD includes medical and supportive approaches. There are two forms of

AMD, dry (non-exudative) versus wet (exudative). There is no medical treatment for dry AMD and the management is supportive. In wet AMD, selected cases may be suitable for medical treatment with anti-vascular growth factor injections, that aim to slow the progression of the disease and vision loss (e.g. intravitreal injections),5,14 but the treatment cannot revert vision to a pre-diagnosis state.

Supportive care with low vision devices is therefore a fundamental part of the management to optimize the activities of daily living for a person with AMD. Low vision devices have existed in LOW VISION DEVICES FOR MACULAR DEGENERATION 4 varying forms for decades (e.g. magnifiers, electronic visual enhancement systems, etc.) and can have a substantial impact on improving outcomes for people with AMD.15

There are other types of supportive care, such as alternative illumination, ergonomic adjustments, rehabilitation and education programs, as well as mobility aids. The combination of these multidisciplinary approaches is important to the long term management of AMD. However, the interest in low vision devices pertains to the fact that the devices can directly manipulate the image formed on the retina. The range of low vision devices can vary dramatically in cost, from free apps, to cheaper magnifiers (AUD$20), and expensive electronic devices (AUD$5,000).16 Depending on the level of support required, buying low vision devices may end up being a larger financial investment compared with making environmental or lifestyle changes. For example, upgrading lighting around a home can significantly improve a visually impaired person’s quality of life.17 Yet, depending on the device, this is a comparatively inexpensive change relative to the thousands of dollars required to purchase expensive low vision devices. Therefore, ensuring that low vision devices have empirically benefited AMD populations is important considering the cost at stake.

Specifications of Low Vision Devices

The primary function of many low vision devices is enhancing the retinal image of objects in the visual field.18 While traditional low vision devices (e.g. hand magnifiers) have been indispensable to the visually impaired community, they are limited in their capabilities due to fixed magnification levels and restriction of the field of view.19,20 Newer low vision devices have the digital processing technology to instantly manipulate the retinal image of the immediate visual field, through contrast, luminance, color correction, remapping, and spatial frequency filtering.20,21 Despite these innovations, this is only the start of what modern low vision devices could become, as eye-tracking technology and augmented reality devices are also being integrated.20

A variety of studies have evaluated different low vision device types on visual acuity, functionality, and usability.20,22 Other factors that may come into play include a person’s comfort with technology and price of the device. Participants in a recent study comparing low- and high- priced head-mounted devices concluded that the high-priced device provided better visual experiences, quality and comfort.22 Interestingly, people do not necessarily purchase the higher-priced device. The LOW VISION DEVICES FOR MACULAR DEGENERATION 5 study found that the participants would still purchase the low-priced alternative, and their feedback suggested that they could not justify the price in exchange for the difference in image quality.22 Thus, research into low vision devices does need to take into consideration that cost-effectiveness and suitability is relative to the individual.

Outcomes of Interventions

Successful management of AMD should extend beyond just enhancing vision, to ensuring that the associated physical, social and psychological domains are also improving as a result of interventions.6,23 Improvements in the ability to read smaller print do not necessarily equate to the individuals’ wellbeing. Hence, research into low vision devices should incorporate measures of emotional experience, subjective experience, and quality of life, in addition to traditional vision assessments. Previous systematic reviews have collated literature on low vision devices and interventions for AMD.24 However, their relevance and significance are somewhat constrained due to more recent advances in technology, especially over the last decade with the new range of low vision devices that have become available.

Recent reviews on AMD tend to focus on a specific domain or outcome measure, for example, depression, quality of life, or reading performance.25-27 However, comprehensive reviews on many outcome measures can be more informative for the visually impaired community. For instance, Binns et al.28 reviewed the literature on visual impairment rehabilitation services, by examining outcomes such as quality of life, health and mood, on top of clinical visual assessments. As such, this review aims to expand the systematic search and evaluate all measures investigated in order to provide an up- to-date analysis of the benefits of low vision devices for people with AMD. LOW VISION DEVICES FOR MACULAR DEGENERATION 6

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) has been followed (see supplementary file).29 The review was not prospectively registered. A systematic search was conducted to identify all studies featuring the use of low vision devices in populations of AMD participants. The following search strategy was used (see Appendix A for the full database strategy):

“Macular degeneration” AND ("Adaptive technolog*" OR aid* OR "assistive technolog*" OR

"augmented realit*" OR beacon* OR computer* OR device* OR "head mount*" OR magnif* OR

"mediated realit*" OR "mixed realit*" OR phone* OR sensor* OR "smart technolog*" OR tablet* OR

"virtual realit*").

Papers were included in the review if they investigated the use of devices that could enhance vision within populations of visually impaired participants with a primary diagnosis of age-related macular degeneration. Eligible papers were required to include at least one measure of the effect the device had on the participants (e.g. vision related, subjective response). They could include participants with other visual impairment conditions (e.g. Glaucoma or Cataract) if there was a separate AMD group or outcome measure reported, or at least 75% of the participant group had a primary diagnosis of AMD. Exclusion criteria included non-experimental, non-peer reviewed publications (e.g. review articles, conference articles, dissertations); case studies <5 people; AMD populations with subsets of comorbid conditions (e.g. Stargardt’s disease); or participants that had medical treatment or surgery (e.g. implants or prosthetics) during the course of the study – although a history of either was accepted.

The search was conducted on August 16th 2019 (followed by an updated search on May 9th

2020) via Ovid, by simultaneously searching five databases: Embase Classic+Embase, Ovid Emcare,

Ovid MEDLINE ® All, Ovid Nursing Database, and PsycINFO. This was accompanied by a search in

IEEE Xplore, using only the search term ‘Macular degeneration’. As this database comprises recent research on advancements in technology, electronics and computer science, it complemented the five medical and allied-health related databases. Given the prestige of conference presentations in technology-related fields of research, conference proceedings indexed in IEEE Xplore were accepted for inclusion in this review. All other inclusion and exclusion criteria were adhered to. LOW VISION DEVICES FOR MACULAR DEGENERATION 7

Screening was managed with Covidence systematic review software. Title and abstract screenings proceeded a full-text screening. The title and abstract screening was conducted by a single reviewer, based upon the pre-agreed selection criteria. A subsequent full-text screening was undertaken independently by two reviewers. A consensus between the two reviewers was required for a paper to be included in the final synthesis. Conflicts on eligibility were discussed, and if a consensus was not reached, a third reviewer was consulted to break the tie. The eligible studies were then examined, and relevant data extracted. The data pertains to what researchers have attempted to evaluate through their studies (e.g. reading performance, appraising rehabilitation programs, etc.); what devices were utilized within studies (e.g. closed-circuit televisions, magnifiers, etc.); the measures and tests that were employed to do so (e.g. vision assessments, self-report questionnaires, etc.); as well as what researchers found (e.g. what effect did the low vision devices have on the measures and tests?). This information was agreed upon by two reviewers prior to data extraction. The predominant data extraction was completed by a single reviewer and checked by a second reviewer.

Throughout the data extraction process, the second reviewer was also consulted when there was ambiguity over relevant data.

The Joanna Briggs Critical Appraisal Tools for Quasi-Experimental Studies (non-randomized experimental studies) was used to evaluate the methodological quality of the included articles.30 Two researchers appraised the articles based on a checklist of nine questions, and disagreements were settled through discussion. The study was classed as having a ‘high’ risk of bias if it met less than

49% of the criteria, a ‘moderate’ risk if it met between 50-69% of the criteria, and a ‘low’ risk if adhered to 70% or more of the criteria. Inter-rater reliability was calculated to assess the consistency of the appraisals using the Cohen’s Kappa method and interpreted as expressed in McHugh.31

Furthermore, the certainty of the evidence was examined using GRADE (Grading of

Recommendations, Assessment, Development and Evaluation)32 – this process was, in part, guided by a GRADE algorithm.33 ‘High quality’ indicates that the authors are confident the true effect is similar to the estimated effect; ‘moderate quality’ is when the true effect is probably close to the estimated effect; ‘low quality’ means the true effect might be markedly different from the estimated effect; and

‘very low’ suggests that the true effect is probably markedly different from the estimated effect. LOW VISION DEVICES FOR MACULAR DEGENERATION 8

Results

The systematic search originally identified 5,443 articles (see Figure 1), with a further 347 new articles revealed in the updated search. After title, abstract and full-text screenings, just 35 articles met the inclusion and exclusion criteria. Appendix B presents the full data on demographics, study purpose, types of devices, measures and tests, findings, risk of bias, and sources of funding and support for each study.

Critical Appraisal: Overall the studies employed methodology that were of a moderate risk of bias. Appendix C presents the individual assessments made by each reviewer, followed by the final agreed criteria decision. Cohen’s Kappa revealed a moderate level of agreement (푘 = 0.63).

Approximately 12% of checklist responses were ‘Unclear’, due to not enough information being provided in the paper to make a definitive judgement about the criteria. As such, the risk of bias may be higher or lower. This was particularly evident for criteria three, “Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest?”. The reviewers agreed that it was not explicitly clear in over half of the studies whether the participants were receiving treatment other than the low vision device – a factor which may have affected their outcomes. Alternatively, it was transparent that a limitation of almost all the studies was the lack of control groups (criteria four) – only four studies were randomized control trials.34-37 While within-group designs are common in this field of study, the internal validity of the studies may be biased.

LOW VISION DEVICES FOR MACULAR DEGENERATION 9

Figure 1. PRISMA flow diagram for low vision device studies in macular degeneration populations.

New records identified Records identified through Additional records identified through the updated search database searching through other sources

(n = 347) (n = 5,443) (n = 0) Identification

Records after duplicates

removed

(n = 3,843) Screening

Records screened Records excluded, with main reasons (n = 4,190) (n = 4,096) Alternative treatments for AMD,

medical research, and different visual

impairments Full-text articles assessed for

eligibility Eligibility (n = 94) Full-text articles excluded, with reasons (n = 59) (20) incorrect format (e.g. review article, dissertation, etc.) Studies included in qualitative synthesis (14) non-English ( 8 ) no separate AMD group or <75% (n = 35) AMD participants ( 8 ) no visual enhancement Included ( 4 ) no AMD participants ( 2 ) alternative treatment ( 1 ) had implant ( 1 ) non-low vision devices ( 1 ) small sample (<5 participants) LOW VISION DEVICES FOR MACULAR DEGENERATION 10

Purpose of the Studies

One of the primary aims of over half (54.3%) of the included studies was to evaluate reading ability or performance in AMD populations, with approximately 77.1% of all studies including at least one type of reading performance measure. The majority of study protocols began with a vision assessment before proceeding to the relevant tasks under investigation. Twelve facets of AMD and low vision devices were explored by researchers (see Figure 2), including the effects of rehabilitation and training programs, evaluating magnification requirements for low vision devices, as well as examining the facial and emotional recognition abilities of AMD participants.

Figure 2. Purpose of age-related macular degeneration research by category.

Vision assessment 31 Reading performance / ability 19 Rehabilitation programs / training 9 Low vision device comparison 4 Low vision device validation 4 Magnification requirements 4 Facial / emotional recognition 3 Low vision device use 3 Page navigation strategies 2 Ergonomic use of low vision devices 1 Psychological assessment 1 Questionnaire validation 1 Number of Studies

Types of Low Vision Devices

Figure 3 depicts the distribution of low vision devices as assigned by category. Magnifiers were the most prevalent devices tested (n = 50). Glasses and / or spectacle-based devices (n = 27), closed-circuit televisions (CCTV) (n = 13), and telescopic devices (n = 13) were the next most commonly tested. A small number of electronic reading devices (n = 7) and head-mounted devices (n

= 7) were examined, e.g. iPad and NuVision respectively; in addition to simple other devices such as a dome and microscope. For the full description of the low vision devices investigated, see Appendix

B. LOW VISION DEVICES FOR MACULAR DEGENERATION 11

Given the proportion of magnifiers, this category can be further broken down into types of magnifiers. This includes stand magnifiers (n = 19), both illuminated and non-illuminated; hand magnifiers (n = 17), illuminated and non-illuminated; and other various formats (n = 14), such as bar, distance, flat-field, lamp, neck, pocket, spectacle, and optical magnifiers. If the magnifiers category were to be redefined to any device with the overall purpose of enhancing vision or content for the user, the number of ‘magnifiers’ would increase further to an estimated 86.6% of all devices assessed.

Figure 3. Low vision devices categories.

Magnifiers 50 Glasses 27 CCTV 13 Telescopes 13 Electronic Reading Devices 7 Head-Mounted Devices 7 Binoculars 4 Lens 4 Unspecified Devices 4 Dome 1 Friang System 1 Microscope 1 Optoelectronic Jittery Glasses 1 Number of Devices

Measures and Tests

Vision assessment. Vision assessment was a fundamental measure in almost all AMD studies.

ETDRS (n = 11), Bailey-Lovie distance letter (n = 6), MNRead (n = 6), and Bailey-Lovie near word

(n = 5) were the most used charts to assess visual acuity; all presenting rows of progressively smaller letters and words that participants were required to read. Other forms (n = 5) of vision assessment included the Monoyer-Granstrom Kifa letter chart and the E-scale (see Table 1 for all vision acuity charts). Contrast sensitivity was another standard assessment in twelve studies. The Pelli-Robson chart (n = 10) was frequently administered, in which participants were asked to read letters from rows as the contrast between the letters and background gradually decreased. Further clinical aspects LOW VISION DEVICES FOR MACULAR DEGENERATION 12 of vision that were evaluated include fixation, microperimetry, scotoma size, and more. See Appendix

B for more details.

Table 1. Charts used to assess visual acuity in age-related macular degeneration populations.

Visual acuity charts Num of studies References ETDRS 11 Ferris et al. (1982)38 Bailey-Lovie (distance) 6 Bailey and Lovie (1976)39 MNRead 6 Mansfield et al. (1993)40 Bailey-Lovie (near) 5 Bailey and Lovie (1976)39 Unspecified 4 NA GP Preisler, Malmö, Sweden 3 (1995)41 Snellen 3 Snellen (1862)42 E-Chart 1 Snellen (1862)42 Lea-Symbol 1 Hyvärinen (1980)43 39 LogMAR 1 Bailey and Lovie (1976) Monoyer-Granstrom Kifa 1 Monoyer (1872)44 Topcon Projector 1 Topcon (2018)45 Seven studies used multiple visual acuity charts. NA: not applicable

Reading performance. Different components of reading performance (n = 27) were examined: reading accuracy, acuity, duration, speed, rate, and critical print size. Standardized text passages and reading assessments are the preferred mediums to appraise these measures, e.g. the

MNRead (n = 7), International Reading Speed Tests (n = 3), and Bailey-Lovie text charts (n = 2).

But studies (n = 6) would also request participants to read text from real everyday items, e.g. newspapers, bills, grocery lists. As listed in Table 2, of the 27 studies that included a measure of reading performance, there were 17 types of materials.

LOW VISION DEVICES FOR MACULAR DEGENERATION 13

Table 2. Materials used to assess reading performance in age-related macular degeneration populations.

Testing materials Num of studies References General / unspecified text 7 NA MNRead chart 7 Mansfield et al. (1993)40 Real items (e.g. medicine bottles, newspaper print) 6 NA International Reading Speed Tests 3 Trauzettel-Klosinski and Dietz (2012)46 Lighthouse cards & chart 3 Silverstone et al. (2000)47 Bailey-Lovie chart 2 Bailey and Lovie (1980)48 Jaeger’s chart 2 Jaeger (1856)49 Maclure children reading book 2 Maclure (1980)50 Oxford Progressive English Readers 2 Oxford University Press (2020)51 Sloan reading cards 2 Sloan and Brown (1963)52 Times New Roman chart 2 Sussex Vision (2020)53 Uni of Waterloo test card 2 Bailey (1986)54 Chinese reading card 1 Wu et al. (1991)55 English Radner Reading Chart 1 Radner et al. (1998)56 Gray Oral Reading Test 1 Wiederholt and Bryant (2001)57 Morgan Low Vision Reading Comprehension Assessment 1 Watson and Wright (1996)58 Neale Analysis of Reading Ability 1 Neale et al. (1999)59 Eight studies used multiple test materials. NA: not applicable

Self-report questionnaires and tests. Thirteen studies used self-report questionnaires and tests

to assess AMD participants on the following health domains: cognition, depression, general health,

quality of life, and vision. Only five self-report questionnaires and tests, the Manchester Low Vision

Questionnaire (n = 3), Mini Mental Status Exam (n = 3), National Eye Institute Visual Function

Questionnaire – 25 (n = 3), Geriatric Depression Scale (n = 2), and Visual Analog Scale (n = 2)

were administered across multiple studies. All others were used once (see Table 3 for all the self-

report questionnaires and tests).

The Mini Mental Status Exam, Montreal Cognitive Assessment and Ocular Health

Assessment were questionnaires only administered as part of eligibility screenings to assess the

participants’ cognition and health status. Whereas the Activity Inventory, Manchester Low Vision

Questionnaire, Visual Analog Scale, and Vision Function Index were instruments used to measure

subjective feelings and attitudes from participants regarding satisfaction, difficulties, comfort and ease

of use with the respective low vision device and tasks.

LOW VISION DEVICES FOR MACULAR DEGENERATION 14

Table 3. Self-report questionnaires and tests used to assess age-related macular degeneration domains. Age-related macular degeneration domains Types of questionnaires / tests Num of studies References Cognition Mini Mental Status Exam 3 Folstein et al. (1975)60 Montreal Cognitive Assessment 1 Nasreddine et al. (2005)61 Short Portable Mental Status Questionnaire 1 Pfeiffer (1975)62 Depression Geriatric Depression Scale 2 Sheikh and Yesavage (1986)63 Center for Epidemiological Studies Depression Scale 1 Radloff (1977)64 Hospital Anxiety and Depression Scale 1 Zigmond and Snaith (1983)65 General Health General Health Questionnaire 1 Owsley et al. (1999)66 Short Form Health Survey – 36 1 Ware and Sherbourne (1992)67 Quality of Life National Eye Institute Visual Function Questionnaire – 25 3 Mangione et al. (2001)68 Nottingham Adjustment Scale 1 Dodds et al. (1993)69 Psychosocial Impact of Assistive Devices Scale 1 Day and Jutai (1996)70 Vision Manchester Low Vision Questionnaire 3 Harper et al. (1999)71 Visual Analog Scale 2 Crichton (2001)72 Activity Inventory 1 Massof et al. (2007)73 Ocular Health Assessment 1 Leat et al. (2017)35 Vision Core Measure – 1 1 Frost et al. (1998)74 Vision Function Index 1 Hart et al. (1999)75 Seven studies used multiple self-report questionnaires and tests.

Subjective feedback. Subjective feedback from participants was examined further in thirteen

studies by directly asking the participants about their feelings and experiences of AMD and low vision

device use. A combination of rating and Likert scales (n = 8), as well as general questions were used

to evaluate this (n = 5). Example questions and statements are presented below:

‘Which did you find easier to use? Handheld CCTV / Stand-mounted CCTV / No preference’.

Goodrich & Kirby p. 524 76

‘I have difficulty recognizing familiar faces in the street. Disagree strongly – Agree strongly’.

Tejeria et al. p. 1020 77

‘How useful did you find the eccentric fixation point to aid reading the text? Not useful –

Very useful’. Walker et al. p. 464 78

LOW VISION DEVICES FOR MACULAR DEGENERATION 15

Findings

General outcomes. As presented in Table 4, researchers found significant positive effects of

low vision devices on vision, reading performance, depression, quality of life, and face recognition.

Generally, the use of low vision devices were highly valued, perceived as useful, or improved a

relative outcome measure in 33 studies. Of the other two studies, one reported no statistical

differences between participant outcomes with and without a low vision device,79 and the other did

not investigate differences in outcomes with and without low vision devices.80 Specifically, measures

of vision and reading ability were significantly improved in the majority of studies (moderate quality

evidence). All three studies assessing facial and emotional recognition found significant gains in

recognition ability with a low vision device (very low quality evidence).77,81,82

Table 4. Outcome measures investigated in age-related macular degeneration populations.

Outcome measures Num of studies Reported findings a Overall evidence Evidence certainty (GRADE)b Vision-related outcomes Objective assessments: i.e. visual acuity 31 (4 RCTs) ↑−−↓ ↑ ⚫⚫⚫⚪ Moderate Reading performance 27 (3 RCTs) ↑−−↓ ↑ ⚫⚫⚫⚪ Moderate Subjective responses: i.e. self-report 7 (1 RCT) ↑−−↓ −− ⚫⚫⚪⚪ Low visual function questionnaires Face recognition 3 ↑−−↓ ↑ ⚫⚪⚪⚪ Very low Task performance: i.e. writing 2 ↑−−↓ −− ⚫⚫⚪⚪ Low Beyond vision outcomes Depression 4 (1 RCT) ↑−−↓ −− ⚫⚫⚪⚪ Low Quality of life 4 (2 RCT) ↑−−↓ −− ⚫⚫⚪⚪ Low General health 2 (1 RCT) ↑−−↓ −− ⚫⚫⚪⚪ Low Cognition 1 ↑−−↓ −− ⚫⚫⚪⚪ Low RCT: Randomized control trial a Direction: ↑ = significant positive effects reported; −− = effects not reaching significance reported; ↓ = significant negative effects reported b GRADE: High quality = authors are confident the true effect is similar to the estimated effect; Moderate quality = the true effect is probably close to the estimated effect; Low quality = the true effect might be markedly different from the estimated effect; Very low quality = the true effect is probably markedly different from the estimated effect

In terms of self-reported findings, there were limited significant improvements as a result of

low vision devices and interventions. Only one study found significantly lower symptoms of

depression and anxiety experienced by people with AMD after the provision of a low vision device.83

A different study reported a positive psychosocial impact of low vision devices after a month of use, LOW VISION DEVICES FOR MACULAR DEGENERATION 16 however this finding did not reach significance.84 Likewise, most studies reported no significant changes to health domains based upon the questionnaires administered (low quality evidence). There was one study that found significantly deteriorated scores on the Vision Core Measure and the Short

Form Health Survey at a twelve-month rehabilitation follow-up – although this was accompanied by a significant decrease in visual acuity as well.37

Subjective feedback from participants also provided varied opinions on the experience, ease of use and preferences for different low vision devices.71,76 For example, the majority of a group of

AMD participants reported a range of difficulty levels using a magnifier, yet they also still reported using magnifiers multiple times each day.71 Another participant group rated magnifiers as being moderately to extremely useful for reading mail, bills and for leisure.85 Some studies reported that the

AMD participants found newer low vision devices (e.g. Epson Moverio BT-200 and electronic reading aids) made reading easier compared to their standard methods,78,86 whereas others showed that printed paper was the easiest medium to read from.87 The researchers suggested that financial considerations and personal characteristics of people with AMD may be a significant factor influencing preferences for low vision devices.76

However, as indicated in Table 4, the certainly of the evidence was generally low to moderate, therefore the real impact of low vision devices may be different from that estimated within the studies. The evidence was consistently downgraded due to the risks of bias at trial and review quality level, as well as varying precision of sample sizes. These judgements were made in consideration of the lack of randomization in the studies’ designs, as well as the moderate risks of bias exhibited by the methodological approaches used.

Rehabilitation and training. Rehabilitation and training programs had a positive impact on outcome measures in eight studies (low quality evidence).34,41,82,88-91 It has been suggested that greater benefits may be derived from low vision devices , if training sessions to develop skills are provided.41,82,91 These benefits were highlighted by Nilsson, in a randomized control trial, to be even better when formal training programs are administered rather than basic instructions.36 A multidisciplinary approach, with a combination of low vision device and rehabilitation services (i.e. LOW VISION DEVICES FOR MACULAR DEGENERATION 17 eccentric viewing training, counselling, education) was also more likely to increase the quality of life for the participants.89

However, the long-term outcomes of rehabilitation need to be better understood. Two studies demonstrated an immediate significant increase to reading performance as a result of initial training sessions;88,90 yet these changes plateaued or slightly waned over the course of the sessions (very low quality evidence). Reasons for these effects have been posited from reaching a maximum reading improvement during the early stages of training, to the concurrent decline in AMD throughout rehabilitation. Another study found that the use of CCTV by itself was more effective than repeated training sessions.35 Moreover, a randomized control trial of three rehabilitation programs for newly diagnosed AMD participants found that participants experienced no more benefits to quality of life or ability to carry out everyday activities, from any specific rehabilitation model over another.37

Participants instead reported significantly worse scores on vision and health related quality of life questionnaires at a twelve month follow up – although these negative changes might not be due to the rehabilitation programs, but once again caused by the progression of AMD.

Device comparisons. Five studies comparing different low vision devices to one another showed that all the devices generated improvements on the measured outcome (low quality evidence).35,76,92-94 The findings of two of these studies also indicated larger improvements with some devices (e.g. CCTV) instead of others (low quality evidence).35,76 Culham et al.93 concluded that younger people with visual impairments can benefit from head-mounted devices (i.e. Jordy, Maxport) more than older people, but generally traditional low vision devices (i.e. magnifiers) can be just as effective. Performance-based measures demonstrated a better reading experience using the more expensive CCTV over other low vision devices – which was complemented by the participants preferences; but participant preferences were divided once cost was a consideration.76 Similarly,

Morrice et al.94 also concluded that a cheaper iPad was just as effective as the expensive CCTV in improving reading speed.

Magnification, page navigation and ergonomic specifications. Studies evaluating magnification produced mixed findings: altering the magnification on low vision devices was found to have a beneficial effect on reading rehabilitation,95 a negative effect on reading speed,91 and no impact LOW VISION DEVICES FOR MACULAR DEGENERATION 18 on reading rate (low quality evidence).79 In terms of the negative effects, it was revealed that when participants increased the magnification on a device, the time taken to read text passages also significantly increased.91 As such, there was evidence that a simple low vision device can be just as sufficient for reading, compared with those with high magnification capabilities.8 Furthermore, the type of AMD (i.e. disciform vs atrophic) could influence the levels of magnification required.96

Two studies surmised that the use of line guides and training can improve reading ability for

AMD individuals (very low quality evidence).80,97 Although, there was evidence that retrace navigation became more difficult with line guides, leading to reduced reading speed.97 Regarding ergonomics, Watson, Ramsey, De l’Aune, and Elk determined that functional interventions (i.e. desk height, stand tilt) significantly increased reading speed and decreased reported discomfort whilst using a low vision device (low quality evidence).98

Discussion

The consensus from most of the studies is that the use of low vision devices does have a positive impact on reading and other aspects of visual performance for AMD populations. Thus, utilization of a low vision device in a person with AMD could be considered an essential part of managing daily life. The research indicates that people with AMD are likely to have preferences for certain devices due to financial, comfort or usability reasons, rather than pure performance based findings.22,76 However, the certainly of the evidence reported ranged from low to moderate, being hindered by risks associated with the methodological approaches and study designs. Adopting stricter experimental protocols in the future, such as randomized control trials, will reduce biases and generate greater confidence in the findings. As it stands, only four studies utilized randomized control trials. Therefore, despite the included studies elucidating nuances of low vision devices, there is a lack of clear evidence for most of the findings.

Simple vs Advanced Low Vision Devices

Studies have shown that simple low vision devices (e.g. magnifiers) can be an effective type of vision enhancement device (low quality evidence). Previous reviews have found similar preferences and empirical evidence for magnifiers amongst visually impaired populations.25,28 The LOW VISION DEVICES FOR MACULAR DEGENERATION 19 fact that this finding has not changed despite the years and newer technology available, speaks to the functionality of magnifying products. Many of the researchers concluded that these, and other simple low vision devices, delivered improvements to vision that were of equal to, or even superior to, the effectiveness of low vision devices that have higher magnification capabilities.8,76,94 Keeping in mind that the evidence for this was of low quality, the small evidence base suggests that newer technologies

(e.g. iPad) may not currently provide a more effective visual enhancement experience compared with traditional ones (e.g. hand-held magnifier). For now, people with AMD should feel reasonably confident in the effectiveness of their current devices.

Head-mounted devices, in particular, are being increasingly advertised in the visually impaired community, yet there is a lack of validated evidence within AMD populations. This is demonstrated in Appendix B such that many studies investigated magnifiers and yet only four studies examined head-mounted devices. 34-37 It is possible that the scientific world has not yet caught up with the changing technological world and research on these devices in AMD populations is still to come.

However equally feasible is that given the rate at which technology evolves, it is likely that by the time research is established on a low vision device, the technology itself may already be outdated. As such, funding bodies may not want to invest in research that could have short-term practical applications.

There are additional studies investigating head-mounted devices (e.g. eSight) within combined visually impaired populations which showed promising results but were not included in this review because these studies did not specifically target AMD.99 The need for specified studies on individualized populations is critical because the requirements for one type of visual impairment differs substantially to another. For instance, retinitis pigmentosa preferentially affects the peripheral retina, leading to decreased night and peripheral vision.100 A fundamental mechanism of any device suited to someone with retinitis pigmentosa is the amplification of light sources and expansion of the field of view.101, 102 While these features are not a hindrance to a person with AMD, there will be limited benefits. In contrast, to be of any assistance, low vision devices marketed at AMD populations should, at a minimum, incorporate a magnifying component (e.g. high-powered lenses) into the underlying technology. LOW VISION DEVICES FOR MACULAR DEGENERATION 20

Demographic of Low Vision Device Users

An important consideration for device suitability is the age of the user. The primary demographic of people affected by AMD are older adults – increasing in prevalence beyond 75 years old.2 This may account for the suggested recommendation of simpler devices over complex ones. As people with AMD age and are contending with equivalent declines in health and cognition, they may prefer the simplicity of a hand magnifier rather than the requirements of a CCTV. Users of head- mounted devices have previously reported limited battery life, motion sickness or being distracted from their experience by difficulties using the device controls.103, 104 These are factors that may affect a person with AMD choosing a simpler magnifier rather than a more complex low vision device.

The current findings are based upon the present generation of older adults, who did not grow up in a technological age of touch screens, smartphones, and tablets. Older adults may not have integrated technology into their daily activities (e.g. banking, shopping, news) as much as younger people.105 Rhodes noted that screen time is inversely proportional to the age of the user.106 Children today are far more flexible and adaptable to technology than all preceding generations, because they are exposed to it from infancy. Thus, over time people who are diagnosed with AMD may be more likely to overcome the barriers and deficits associated with embracing newer and more technological low vision devices.

Measures for Assessing Age Related Macular Degeneration

The systematic review identified a range of measures used to assess vision, reading and other domains in AMD populations. The wide variety of measures can make comparing outcomes between studies challenging, especially when the measures are administered in different contexts. For example, the MNRead is a chart of continuous text designed to measure reading acuity.40 Yet there were six studies in which the MNRead was used by the researchers as an assessment of vision rather than reading performance.

There is also likely to be variability in the psychometric properties of the measures used; therefore, some studies may have employed tools that were more sensitive than others at assessing the intended construct. This may be less of a problem for vision assessments as many charts, including the Bailey-Lovie and ETDRS charts, are formatted to reflect the guidelines of LogMAR charts. The LOW VISION DEVICES FOR MACULAR DEGENERATION 21 original LogMAR chart (i.e. the Bailey-Lovie chart) was specifically designed by the National Vision

Research Institute of Australia, with optimal fonts, text sizes, spacing and number of letters in mind, in order to set an industry standard for evaluating visual acuity.39 The LogMAR chart has long been more accepted compared with the original Snellen chart.42

Regarding reading performance, there were 17 variations of materials presented to AMD participants (see Table 2). These included standardized materials such as the abovementioned

MNRead, International Reading Speed Tests and Lighthouse cards, but also general text and words from real items (e.g. bills, medicine bottles). The latter makes it difficult for future researchers to replicate studies and findings since the content is not specified in the study papers. On the other hand, the use of real items provides a realistic representation of text that people with AMD struggle with on a daily basis; the findings of which are also more generalizable for the visually impaired community.

Some instruments, such as the Melbourne Low-Vision ADL Index and Very Low Vision Instrumental

Activities of Daily Living,107,108 examine more than just reading performance (e.g. writing a check, threading a needle, pouring drinks). None of the 35 studies included in this review utilized these multi-domain instruments, but they have been administered in other vision impairment studies to measure vision-related disability.99

The Implications of Home vs Laboratory Studies

Beyond the specific use of measures, variability extends to the design of studies as well. Low vision devices were used within single event experiments in laboratories or clinics,82,86 as well as at home or over a long time periods.35,84,90 The varying designs align with the need to assess different outcomes in different environments – just as mentioned above, using real life items offers a greater degree of ecological validity. As such, when participants can take low vision devices home, they are able to practice with them in everyday activities that they typically struggle with, whereas a laboratory environment has more artificial tasks. Furthermore, home based studies are able to offer insights into the long-term effects of low vision devices, beyond participants’ initial engagement with them.

In this review, significant improvements to outcome measures (e.g. reading performance) were found in both single laboratory studies and during the early stages of long-term home based studies (low-moderate quality evidence).41, 90, 94 However for the latter studies, just like with the LOW VISION DEVICES FOR MACULAR DEGENERATION 22 rehabilitation studies discussed earlier, the positive effects of the low vision devices were reported to plateau or ebb after a period of time (or equally possible as a result of the progression of AMD).84, 90

This suggests that a peak effect of low vision devices is reached initially whilst using a device. A finding such as this is only revealed during real world experiments in which the participants are tested over weeks or months. Were recommendations to the visually impaired community to be purely based upon single laboratory studies, people with AMD may assume that low vision devices will always demonstrate an increased change. Generally, this could indicate that laboratory studies may not be the best predictor of real world effectiveness for low vision devices; however the degenerative nature of

AMD also makes it difficult to isolate the effects of devices from the condition itself.

Quality of Life for People with Age Related Macular Degeneration

There is encouraging findings that low vision devices may be able to improve a person’s overall quality of life, although currently the results are based on a small number of studies (low quality evidence). While vision-related outcomes appear to prosper from the use of low vision devices, the results of the self-report questionnaires indicated that there was limited significant evidence for or against improvements to health domains beyond vision and reading performance.

Given the amount of literature linking the impact of AMD on various physical, social and psychological domains,7,10-13 as vision improves it was likely anticipated that the low vision devices would also generate positive carry-over effects into these other domains. A potential reason for the scarce evidence so far is that only a few studies investigated the long-term benefits of low vision devices beyond vision.

Another reason why not all of the studies reported positive quality of life effects could be that improvements resulting from low vision devices may not have enough of an impact to make up for deficits in other areas. Low vision devices are habitually used for static or stationary activities, such as reading, and may not be applicable in tasks that require mobility, like crossing a road. Therefore, people with AMD may not experience benefits to activities of daily living beyond a few activities – although it is acknowledged that for some visually impaired individuals an improvement to these may be enough; for example, a individual who enjoys reading all day. The continued struggles accomplishing mobile activities (e.g. cooking, walking, shopping) may sustain people’s negative LOW VISION DEVICES FOR MACULAR DEGENERATION 23 feelings even when the low vision devices are effective. Therefore, the findings from the self-report questionnaires and tests may not have accounted for these other variables. Perhaps a combination of devices that incorporate both static and mobility functionality would generate even greater changes to quality of life if more components of daily living were being made easier.

Performance Testing vs Self-reporting

The limited results illustrating changes to quality of life could also be explained by the strategies used to collect them. Self-reports might not be the most accurate measure because they rely on subjective judgements about an emotion or behavior, rather than an assessment of the construct itself.109 There is an assumption that an individual has the necessary self-awareness to judge their own behaviors and psychological state. In the current review, no association was found between performance based measures compared with subjective ratings on the same outcomes.77,80 Previous research has also revealed discrepancies between self-reported difficulty ratings and task performance for visually impaired participants.110,111 For example, a study found inconsistencies between participants reported struggles reading a newspaper and their actual reading speed results on a standardized test.110

Relying entirely on either self-reports or performance testing alone may not be the best practice for evaluating the functional status of people with AMD. The combination of objective and subjective measures can offer a more informed picture of life with AMD; especially since performance based testing does not always reflect a real world environment.111 In the future, a mixture of methodological approaches should be implemented in order to collect unbiased quantitative data, as well as the qualitative data capturing emotions and experiences. For example, researchers could assess stress levels experienced by people with AMD whilst shopping using low vision devices, by evaluating both self-report scales as well as physiological measures. Wearable biometric technology can be provided to participants to collect data on heart rate, skin conductance and physical movements, which in turn can be interpreted to reflect specific emotions.112 These would be a useful addition to performance testing as they could endorse the self-reported feelings and behaviors of those with AMD.109

LOW VISION DEVICES FOR MACULAR DEGENERATION 24

Limitations and Potential Biases in the Review Process

This review was not prospectively registered and there is thus no public record on the priory decisions we made to guard against reporting biases. The choice and allocation of devices, measures and outcomes to categorical groups may have introduced bias into this review. However, these types of categorizations were carefully considered by two researchers to facilitate a simplified assessment of the findings. Furthermore, there was also a risk of bias in our selection criteria for the included studies. By directing the focus of the review on ‘age-related’ macular degeneration, multiple studies were excluded with samples of alternative macular degeneration populations (e.g. Charles Bonnet

Syndrome). The different presentation of symptomology and resultingly, the different management and supportive care approaches required, are what prompted this decision. Nevertheless, we recognize that there would be some low vision devices that would likely offer similar visual improvements to all types of macular degeneration.

In addition, while the role of rehabilitation and training programs on low vision devices was discussed, the impact of specific types of rehabilitation programs was not. For example, eccentric viewing training was a technique adopted by several studies in this review,35-36 but the implications of what this type of training can have on those with AMD was not explored. While this decision could be construed as bias, analyzing the effects of each type of rehabilitation program employed by the included studies would have exceeded the parameters of this review. In fact, examining the impact of rehabilitation programs alone on AMD populations could be a specified review in itself.

The Future of Low Vision Devices for the Visually Impaired

Considerations for future low vision devices should delve deeper into how the devices can target the various manifestations of AMD. Blurred vision, central scotomas, depth impairment, light sensitivity, and reduced contrast sensitivity can all be symptoms of AMD. Patients may only experience one of these, or all. While magnification remains a crucial component in overcoming the deficits caused by AMD, technology developers might consider that their products also have the capabilities to address these other aspects of visual impairments. Another consideration is the cost of the low vision devices. Unless companies can find ways to minimize the price of expensive low vision devices, they may forever be out of reach for many people with visual impairments. Cost LOW VISION DEVICES FOR MACULAR DEGENERATION 25 effectiveness was previously examined by Binns et al.28 who concluded that there was limited evidence on the cost benefits of low vision services.

Overall, the findings of this review have demonstrated that low vision devices have a significant effect on improving participant outcomes, primarily vision and reading performance.

However, more empirical research yielding high-quality evidence needs to be conducted. The current state of research would suggest that there is a preference for simpler low vision devices rather than advanced technology amongst AMD populations. A caveat to this is that there is a lack of high-quality studies examining newer technologies for people with AMD. Until such a time when head-mounted devices or CCTV are more financially accessible to consumers or have overcome the usability challenges faced by older adults, traditional magnifiers are likely to remain the preferred methods for vision enhancement in AMD.

Acknowledgements: AM is supported by the Australian Government Research Training

Program Scholarship and TL is funded by a National Health and Medical Research Council

(NHMRC) Dementia Research Leadership Fellowship (GNT1136269). There were no sources of conflict. LOW VISION DEVICES FOR MACULAR DEGENERATION 26

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LOW VISION DEVICES FOR MACULAR DEGENERATION 36

Appendix A. Database search strategies.

August 26th, 2019

Ovid

Within Ovid, five databases were selected to be searched simultaneously.: 1. Embase Classic+Embase 1947 to 2019 August 23, 2. Ovid Emcare 1995 to 2019 week 34 3. Ovid MEDLINE(R) ALL 1946 to August 23, 2019 4. Ovid Nursing Database 1946 to August Week 3 2019 5. PsycINFO 1806 to August Week 3 2019

No limits were used.

# Search terms 1 augmented realit* 2 virtual realit* 3 mediated realit* 4 mixed realit* 5 head mount* 6 aid* 7 device* 8 magnif* 9 assistive technolog* 10 adaptive technolog* 11 smart technolog* 12 tablet* 13 phone* 14 sensor* 15 beacon* 16 computer* 17 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 18 macular degeneration 19 17 and 18

IEEE Xplore

# Search terms 1 macular degeneration

LOW VISION DEVICES FOR MACULAR DEGENERATION 37

Updated search: May 9th, 2020

Ovid

Within Ovid, five databases were selected to be searched simultaneously.: 1. Embase Classic+Embase 1947 to 2020 May 6, 2. Ovid Emcare 1995 to 2020 week 18 3. Ovid MEDLINE(R) ALL 1946 to May 7 2020 4. Ovid Nursing Database 1946 to April Week 5 2020 5. PsycINFO 1806 to May Week 1 2020

No limits were used.

# Search terms 1 augmented realit* 2 virtual realit* 3 mediated realit* 4 mixed realit* 5 head mount* 6 aid* 7 device* 8 magnif* 9 assistive technolog* 10 adaptive technolog* 11 smart technolog* 12 tablet* 13 phone* 14 sensor* 15 beacon* 16 computer* 17 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 18 macular degeneration 19 17 and 18 20 limit 19 to yr="2019 -Current"

IEEE Xplore

# Search terms 1 macular degeneration

Specify Year Range: 2019-2020 LOW VISION DEVICES FOR MACULAR DEGENERATION 38

Appendix B. Purpose, devices, measures, findings, risk of bias, and sources of funding and support from low vision device research in age-related macular degeneration populations.

Study Population (AMD) Study Purpose Type of Device Measures & Tests Findings Risk of bias Altinbay et al. n = 21 Evaluating vision and reading Telescopic glasses (Galileo & Near & distance VA – Turkish MNRead & unspecified chart Reading performance improved with Low risk (2016)B1 15 atrophic & 12 performance measured with and Kepler) Reading performance - MNRead LVD use exudative without LVD 푀 = 74.11 VA 1 = 1 − 1.3

Amore et al. n = 24 Evaluating vision and reading Aplanatic magnifier Near & distance VA – ETDRS & Italian MNRead Vision better due to LVD; magnification Low risk (2016)B2 ring scotoma performance with LVD Binocular device Contrast sensitivity – Pelli-Robson provides satisfactory rehabilitation 푀 = 80.4 CCTV Microperimetry, fixation, & stability assessment – MP-1 VA = 0.2 − 0.6 Optical magnifier Microperimeter Reading performance – text passages

Ballinger et al. n ≅ 53 Evaluating vision and validating Eschenbach 3X telescope VA – ETDRS Vision improved with LVD; no Moderate risk (2000)B3 푀 = 68.0 LVD via assessment and feedback Low vision enhancement system Contrast sensitivity – Pelli-Robson differences between the AMD and other VA = 0.5 − 1.6 Subjective feedback - questions VI group; no difference between the LVD groups Non AMD: glaucoma, histoplasmosis, optic atrophy & others n ≅22

Bowers et al. n = 43 Evaluating vision and assessing Hand magnifier Near & distance VA – Bailey-Lovie letter & word chart, & MNRead Navigation strategy improved with Moderate risk (2007)B4 67% scotoma page navigation strategies during Stand magnifier Fixation training; no relationship between LVD 푀 = 80.0 reading tasks with LVD Central vision field and navigation patterns; subjective self- Magnifier movements – 3SPACE Isotrack System rated difficulties navigating not related Reading task – text passages (Oxford Progressive English Readers) to actual difficulties Subjective feedback - scale

Calabrese et al. n = 12 Evaluating vision and validating Gaze controlled vision Distance VA – ETDRS Facial recognition improved with LVD; Low risk (2018)B5 푀 = 79.0 LVD with facial recognition task enhancement system Contrast sensitivity – Pelli-Robson participants more comfortable with LVD Scotoma size, fixation stability, PRL eccentricity – MP-1 compared with no LVD Microperimeter Eye tracking – EyeLink Eye Tracker Subjective feedback - scale

Cheong et al. n = 19 Evaluating vision and Hand magnifier Near & distance VA – Bailey-Lovie word chart Magnifiers do not reduce reading rate Moderate risk (2002)B6 푀 = 78.7 determining optimal Stand magnifier Reading rate & CPS – MNRead, Neale Analysis of Reading Ability & for experience LVD users; fixed acuity VA = 0.4 − 1.3 magnification for reading, with text passages (Bailey-Lovie text chart; Maclure Children reading reserve (0.3 Log) is sufficient for reading and without LVD book; Sloan reading cards; Uni of Waterloo near vision test) Magnification levels Micronta LCD stopwatch

Cheong et al. n = 29 Evaluating vision and assessing Stand magnifier (with & without Near & distance VA – Bailey-Lovie distance & word charts Line guides improve forward navigation Low risk (2009)B7 푀 = 80.0 page navigation strategies with line guide) Contrast sensitivity – Pelli-Robson but created difficulties retracing; leads VA = 0.38 − 1.26 and without LVD and line guides Visual field – tangent screen to slower reading speeds Magnifier movements – 3SPACE Isotrak Reading performance – text passages (Oxford Progressive English Readers) Subjective feedback - questions

Cheong et al. n = 32 Evaluating vision and reading Stand magnifier (with Near & distance VA – Bailey-Lovie letter & word chart Reading rates improve initially with LVD Low risk (2005)B8 푀 = 80.3 performance after practice illumination) Contrast sensitivity – Pelli-Robson use and training, then no further; in- VA = 0.18 − 1.1 effects with and without LVD Visual field – tangent screen office practice achieves maximum Vision - MLVQ LOW VISION DEVICES FOR MACULAR DEGENERATION 39

Study Population (AMD) Study Purpose Type of Device Measures & Tests Findings Risk of bias Reading rate & CPS – text passages (Bailey-Lovie text chart, reading rate and home training makes MNRead, Lighthouse reading cards; Maclure Children reading no further improvement book; Sloan reading cards; Uni of Waterloo near vision test) Subjective feedback – questions

Culham et al. n = 10 Evaluating vision and comparing Aspheric magnifier Near & distance VA – Bailey-Lovie word chart & ETDRS Vision improved with LVD; younger Low risk (2004)B9 푀 = 73.5 LVD performances Binoculars Contrast sensitivity – Pelli-Robson people benefit from head mounted LVD, VA = 0.48 − 1.78 DS reader Reading speed & accuracy – text passages (medicine bottle & however traditional LVDs are better and Flat-field magnifier newsprint) head mounted devices recommended Non AMD: early onset Flipperport Visual task performance – cheque writing & selecting grocery only when needed macular disease Hand magnifier (with & without items n = 10 illumination) 푀 = 41.8 Hyperocular Jordy Maxport Monocular telescope NuVision Pocket magnifier Stand magnifier (with & without illumination) Spectacles

DeCarlo et al. n = 181 Evaluating vision and use of LVD, Hand magnifier Near & distance VA – ETDRS & MNRead Majority of people used LVD for at least High risk (2012)B10 푀 = 82.4 with follow up Lamp magnifier Contrast sensitivity – Mars Contrast Sensitivity Test three months; LVD were useful, VA = 0.51 − 1.11 Neck magnifier Visual field, fixation & scotomas – Microperimetry Rodenstock especially for reading Stand magnifier Scanning Laser Ophthalmoscope Telescopes (binocular & Quality of life – NEI-VFQ 25 monocular) General health – General Health Questionnaire Cognition – Short Portable Mental Status Questionnaire Depression – Center for Epidemiological Studies-Depression Scale Subjective feedback – questions

Eklund and Dahlin- unspecified Evaluating vision and assessing CCTV Distance VA – Monoyer-Granstrom Kifa letter chart Assistive devices combined with High risk Ivanoff (2007)B11 rehabilitation with assistive Filter glass Subjective feedback – outcome of rehabilitation programs & LVD rehabilitation have improved outcomes devices and health programs, Hand magnifier use for daily living; no association between with follow up Lamp magnifier number of devices and improvements in Reading glass daily living; assistive devices should be Stand magnifier (with & without prescribed during early stages of illumination) diagnosis TV binoculars

Frennesson et al. n = 10 Evaluating vision and reading Hyperoculars Near & distance VA – GP letter chart Reading speed improved after training High risk (1995)B12 푀 = 80.1 performance after rehabilitation Eccentricity & scotoma – computer software training program Reading speed – text passages (newspaper)

Gill et al. (2013)B13 n = 27 Comparing rehabilitation for iPad Reading speed – iREST & text passages LVD are beneficial for reading Moderate risk 푀 = 78.9 reading with LVD and large print Sony eReader Vision – VAS rehabilitation; participants preferred VA = worse than 0.1 large print over LVDs

Goodrich and Kirby n = 17 Evaluating vision and comparing Hand CCTV VA – LogMAR VA not affected by type of LVD; CCTV is Moderate risk (2001)B14 푀 = 73.3 LVD for reading Microscopic lenses Contrast sensitivity – Pelli-Robson better than other devices for reading VA = 0.48 − 1.6 Stand CCTV Reading speed & duration – text passages performance; preference for CCTV until Stand magnifier (Coil & Subjective feedback – questions cost is considered Non AMD: diabetic Eschenbach) retinopathy, macular hole, cone dystrophy n = 5

LOW VISION DEVICES FOR MACULAR DEGENERATION 40

Study Population (AMD) Study Purpose Type of Device Measures & Tests Findings Risk of bias Haji et al. (2014)B15 n = 73 Evaluating vision and validating iPad VA – unspecified chart Reading ability improved with iPad; iPad Moderate risk range = 58 − 92 LVD for reading Reading ability – text passages (New York Times) a suitable alternative to larger head VA (mean) = 1.6 mounted devices

Non AMD: diabetic retinopathy & others n = 155

Harper et al. n = 47 Validating use of the MLVQ, with Bar/brightfield magnifier Vision – MLVQ Confirmed feasibility of MLVQ in AMD High risk (1999)B16 푀 = 81.4 follow up Distance telescopic device populations Hand magnifier Spectacle magnifier Stand magnifier (with & without illumination)

Huber et al. n = 68 Assessing LVD use, with follow CCTV Quality of life – NEI-VFQ 25 & Psychosocial Impact Of Assistive Functional vision stable for six months Low risk (2008)B17 푀 = 82.0 ups Devices Scale after LVD use; psychosocial impact VA (mean) = 0.91 peaked at one month then waned; important to measure long-term outcomes

Khan et al. n = 91 Evaluating vision and LVD use Hand magnifier Vision assessment – clinical examination, case history, Reading performance improves with Moderate risk (2002)B18 푀 = 69.2 after rehabilitation program Lenticular lenses illumination, refraction, biomicroscopy, funduscopy & more simple and affordable LVD; quality of life Spectacle magnifier Near & distance VA – Snellen chart & LH-Lea Symbol cards improves with combined rehabilitation Stand magnifier Reading performance – text passages and LVD use Telescope Writing performance

Latham (2018)B19 n = 57 Evaluating vision and use of LVD Distance magnifier Near & distance VA – Bailey-Lovie LogMAR chart LVD improves reading performance; Low risk 55 AMD & 2 macular for reading rehabilitation, with Flat-field magnifier (with Contrast sensitivity – Pelli-Robson baseline vision assessments cannot pathologies and without LVD illumination) Vision – Activity Inventory predict future improvements in reading 푀 = 78.0 Hand magnifier (with & without Depression – GDS illumination) Reading performance – MNRead & Reading Accessibility Index Non AMD: glaucoma, Stand magnifier (with (mean reading speed divided by 200) diabetic retinopathy, illumination) Subjective feedback optic neuritis & others Other unspecified LVDs n = 43

Leat et al. n = 10 Evaluating vision and comparing CCTV Vision assessment – case history Use of LVD more effective than eccentric Moderate risk (2017)B20 푀 = 82.8 outcomes of reading Other unspecified LVDs Near & distance VA – ETDRS chart viewing training at improving reading VA = 0.9 − 1.3 rehabilitation programs Contrast sensitivity speed; eccentric viewing still helpful for Reading acuity – Lighthouse chart increased VA Vision health – Ocular Health Assessment Quality of life – NEI-VFQ 25 Depression – GDS Cognition – MMSE Reading performance, speed & accuracy – reading bills, food packages, medicine bottles, & text passages (fifth-grade level)

Morrice et al. n = 57 Evaluating vision and comparing CCTV Demographic – demographics & reading questionnaire All LVD improved reading speed; iPad as Moderate risk (2007)B21 any age LVD for reading iPad VA – ETDRS chart effective as CCTV but cheaper option, VA = 0.6 − 1.18 Other unspecified LVDs Cognition – Montreal Cognitive Assessment therefore iPad is viable alternative Vision – Vision Function Index Non AMD: diabetic Reading performance – iREST (sixth grade) retinopathy, glaucoma & others n = 43

LOW VISION DEVICES FOR MACULAR DEGENERATION 41

Study Population (AMD) Study Purpose Type of Device Measures & Tests Findings Risk of bias Moshtael et al. n = 18 Assessing reading performance Epson Moverio BT-200 Reading acuity, speed & CPS – English Radner Reading Chart Use of LVD improved reading speed; Moderate risk (2019)B22 푀 = 81 and validating LVD Other unspecified LVDs Subjective feedback - questions participants preferred using Epson smart glasses instead of their habitual visual aids

Nguyen et al. n = 15 Evaluating vision, assessing CCTV Distance VA – EDTRS Rehabilitation via LVD is important post- Moderate risk (2007)B23 푀 = 77 magnification requirements for High reading additions Magnification testing – Zeiss chart & newspaper print surgery; all participants could read with VA = 0.3 − 1 reading with LVD and quality of Optical magnifiers Reading speed – text passages LVD; improvement in subjective life Subjective feedback – questions evaluation of vision function

Nguyen and n = 656 Evaluating vision and assessing CCTV Distance VA – EDTRS Decreased reading speed with higher Moderate risk Trauzettel- 푀 = 79.0 magnification requirements for Electronic reading device Magnification testing – Zeiss chart & newspaper print magnification; early adaption and Klosinski (2009)B24 reading, with and without LVD Optical LVD Reading speed – iREST training with LVD better for reading ability

Nguyen et al. n = 530 Evaluating vision, assessing CCTV Distance VA – EDTRS Use of LVD beneficial for improving and Moderate risk (2009)B25 푀 = 82.0 magnification and comparing High reading additions Magnification testing – Zeiss chart & newspaper print maintain reading ability; depending on reading, with and without LVD Hyperoculars Reading speed – text passages magnification requirements, simple LVDs Magnifiers are sufficient for reading Telescope

Nilsson (1990)B26 n = 40 Evaluating vision and Friang system Near, distance & immediate VA – GP chart LVD beneficial for vision and reading Low risk 푀 = 76.9 rehabilitation program, with and Hand magnifier (with & without Reading performance – T-scale chart (Jaeger’s chart & Times New ability; formal training program more VA = worse than 1.0 without LVD illumination) Roman chart) effective than basic instructions for Hyperoculars improving vision Near addition Prismatic Loup system Spectacles Stand magnifier (with illumination) Telescope

Nilsson and n = 120 Evaluating vision and CCTV Near, distance & immediate VA – GP chart Rehabilitation via LVD and training High risk Nilsson (1986)B27 66 senile, 48 disciform rehabilitation program, with and Hand magnifier (with Reading ability – T-scale (Jaeger’s chart & Times New Roman sessions are successful; effects of & 6 hereditary without LVD illumination) chart) rehabilitation are immediate but wane 푀 = 72.0 Hyperoculars after sessions Near addition Prismatic Loup system Spectacles Stand magnifier (with illumination) Telescope

Reeves et al. n ≅ 204 Evaluating vision and comparing Unspecified LVDs Distance VA – Snellen chart High use of LVD during rehabilitation Moderate risk (2004)B28 푀 = 81.3 rehabilitation programs, with Vision – MLVQ & Vision Core Measure 1 program and follow up suggests value of VA = 0.48 − 1.78 follow up General health – Short Form Health Survey - 36 LVD; large effect of AMD on quality of Psychological adjustment – Nottingham Adjustment Scale life Reading performance – grocery items & medicine bottle

Rishi et al. n = 5 Evaluating vision and assessing Dome Near VA – unspecified chart LVD use improves anxiety and Moderate risk (2017)B29 푀 = 38.2 psychological state, with and Glass addition Anxiety & depression – Hospital Anxiety and Depression Scale depression; vision care important part of VA = worse than 0.48 without LVD Pocket magnifier maintaining mental health following Spectacles diagnosis Stand magnifier

Tejeria et al. n = 30 Evaluating vision and face and Ocutech visual enhancement Distance VA – ETDRS Increased facial and expression Moderate risk (2002)B30 bilateral emotional recognition abilities, system telescope Reading acuity – Lighthouse chart & MNRead recognition with LVD; no association 푀 = 81.5 with and without LVD Contrast sensitivity – Pelli-Robson LOW VISION DEVICES FOR MACULAR DEGENERATION 42

Study Population (AMD) Study Purpose Type of Device Measures & Tests Findings Risk of bias VA = 0.4 − 1.4 Colour vision – Farnsworth D-15 Color Vision Test between facial recognition perceived Picture task disability and actual ability Face recognition task Subjective feedback – questions

Virtanen and n = 58 Evaluating vision and comparing CCTV Distance VA – Snellen chart & Topcon Projector LVD use more beneficial for near rather High risk Laatikainen 70.3% atrophic & LVD use with reading task Compound double convex lens Reading acuity – text passages (newspaper print) than distance reading; disciform AMD (1991)B31 29.7% disciform system requires higher LVD magnification than 푀 = 75.2 Fonda’s glasses atrophic AMD Hand magnifier Hyperoculars Loupelens Stand magnifier Spectacles Telescope

Walker et al. n = 26 Evaluating vision and reading iPad (MD_evReader app) VA – MNRead Reading performance better with Moderate risk (2016)B32 binocular performance Reading acuity & speed – text passages (MNRead scrolling text than static text; 푀 = 75.8 sentences) participants reported a positive VA = 0.3 − 0.83 Subjective feedback – questions experience using the app

Watson et al. n = 12 Evaluating vision and different CCTV Near VA – MNRead Correct positions when using LVD Low risk (2004)B33 푀 ≥ 70.0 ergonomic layouts during Hand magnifier Cognition – Folstein MMSE benefits people with AMD; ergonomic reading performance Spectacle magnifier Vision – VAS interventions increase reading speed Stand magnifier Reading ability, rate & CPS – MNRead, Morgan Low Vision and decrease discomfort using LVD Reading Comprehension Assessment & Gray Oral Reading Tests

Watson et al. n = 7 Evaluating vision and face Optoelectronic jittery glasses Distance VA – Bailey-Lovie chart LVD improved facial recognition; LVDs Moderate risk (2012)B34 푀 = 80.0 recognition ability Contrast sensitivity – Pelli-Robson with image jitter can improve quality of (Experiment 3) Cognition – MMSE life Emotion discrimination

Wu et al. (1991)B35 n = 14 Evaluating vision, with and Hand magnifier Near & distance VA – E-chart LVD use improves near and distance VA High risk scotoma without LVD Microscope Reading ability – Chinese reading card 푀 = 68.2 Spectacles VA = 1.52 − 0.52 Telescope

AMD=age-related macular degeneration; CCTV=closed-circuit television; CPS=critical print size; ETDRS=early treatment diabetic retinopathy study; GDS=geriatric depression scale; iREST=international reading speed test; LogMAR=logarithm of the minimum angle of resolution; M=participants mean age; LVD=low vision device; MLVQ=Manchester low vision questionnaire; MMSE=mini mental status exam; NEI-VFQ 25=national eye institute visual function questionnaire; VA=vision acuity; VAS=visual analog scale1 All visual acuities reported in LogMAR format

Studies Sources of funding and support Altinbay et al. (2016)B1 None Amore et al. (2016)B2 None Ballinger et al. (2000)B3 Funded by the Department of Veterans Affairs, Rehabilitation Research and Development grant (#638-3D) Funded by Department of Vision Sciences, Glasgow Caledonian University; the School of Optometry, Queensland University of Technology; the Bowers et al. (2007)B4 Schepens Eye Research institute, NIH grant (#EY12890); and the Queensland University of Technology International Postgraduate Research Scholarship Calabrese et al. (2018)B5 Funded by the Essilor International PhD grant; and the Fondation de France, Berthe Fouassier post-doctoral grant LOW VISION DEVICES FOR MACULAR DEGENERATION 43

Cheong et al. (2002)B6 Funded by the Queensland University of Technology International Postgraduate Research Scholarship Funded by the Department of Vision Sciences, Glasgow Caledonian University grants; the NIH grant (#EY002934); and the Queensland University Cheong et al. (2009)B7 of Technology International Postgraduate Research Scholarship Cheong et al. (2005)B8 Funded by the Queensland University of Technology International Postgraduate Research Scholarship Culham et al. (2004)B9 Supported by the Macular Disease Society DeCarlo et al. (2012)B10 Not reported Eklund and Dahlin-Ivanoff Not reported (2007)B11 Funded by the Crown Princess Margareta's Foundation for the Visually Handicapped; the Edwin Jordan's Foundation for Ophthalmological Frennesson et al. (1995)B12 Research; and the Swedish Medical Research Council (Project No: 12X-734) Gill et al. (2013)B13 None Goodrich and Kirby Funded by the Western Blind Rehabilitation Center, Veterans Affairs Palo Alto Health Care System; and the Innoventions, Inc. grant (2001)B14 Haji et al. (2014)B15 None Harper et al. (1999)B16 Funded by the College of Optometrists Research Scholarship; and the Wellcome Trust Vacation Scholarship Huber et al. (2008)B17 Funded by the Canadian Institutes of Health Research grant (MOP-74522) Khan et al. (2002)B18 Not reported Latham (2018)B19 Funded by the College of Optometrists Leat et al. (2017)B20 Funded by the Lawson Research Institute (Lawson IRF-063-08 and SJHC Foundation-Jarmain Family Fund) Funded by the Vision Research Network; the Fonds de recherche du Québéc – Santé (#28881, #30620, and #32643); the Antoine Turmel Morrice et al. (2007)B21 Foundation; and the MAB-Mackay Foundation Funded by the Lothian Health Foundation; the Centre for Doctoral Training in Applied Photonics, the Engineering and Physical Sciences Research Moshtael et al. (2019)B22 Council (EP/L01596X/1); and the Medical Research Council Confidence in Concept Nguyen et al. (2007)B23 Supported by the Hartmann-Stiftung and the Herbert-Funke Stiftung. Nguyen and Trauzettel- Supported by the Herbert-Funke Foundation Klosinski (2009)B24 Nguyen et al. (2009)B25 Supported by the Herbert-Funke Foundation; and the Hildebrandt Foundation Funded by the Crown Princess Margareta's Fund for the Visually Handicapped; the Edwin Jordan's Foundation for Ophthalmological Research; Nilsson (1990)B26 the Swedish Medical Research Council (Project No. 12X-734); and the Karin Sandqvist's Foundation Nilsson and Nilsson Funded by the Delegation for Social Research grant (DSF 83/60:1); and the Swedish Medical Research Council (Project No. 12X-734) (1986)B27 Funded by the North West Regional Health Authority grant (RDO/18/39); and the Manchester Royal Eye Hospital General Research endowment Reeves et al. (2004)B28 fund LOW VISION DEVICES FOR MACULAR DEGENERATION 44

Rishi et al. (2017)B29 None Tejeria et al. (2002)B30 Not reported Virtanen and Laatikainen Funded by the Sokeain Ystavat ry (1991)B31 Walker et al. (2016)B32 Funded by the ESRC; and the Macular Society (Knowledge Exchange Scheme ES/L001934/1) Watson et al. (2004)B33 Funded by the Rehabilitation Research and Development Center on Vision Loss and Aging, Atlanta Medical Center developmental grant (C203) Watson et al. (2012)B34 Supported by the College of Optometrists; and the Wellcome Trust (VS/07/GLAC/A2) Wu et al. (1991)B35 Not reported

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B30. Tejeria L, Harper RA, Artes PH, et al. Face recognition in age related macular degeneration: perceived disability, measured disability, and performance

with a bioptic device. Br J Ophthalmol 2002; 86: 1019-26.

B31. Virtanen P, Laatikainen L. Primary success with low vision aids in age-related macular degeneration. Acta Ophthalmol 1991; 69: 484-90. LOW VISION DEVICES FOR MACULAR DEGENERATION 47

B32. Walker R, Bryan L, Harvey H, et al. The value of tablets as reading aids for individuals with central visual field loss: an evaluation of eccentric reading

with static and scrolling text. Ophthalmic Physiol Opt 2016; 36: 459-64.

B33. Watson GR, Ramsey V, De l’Aune W, et al. Ergonomic enhancement for older readers with low vision. J Vis Impair Blind 2004; 98: 228-40.

B34. Watson LM, Strang NC, Scobie F, et al. Image jitter enhances visual performance when spatial resolution is impaired. Vis Psycho Physiol Opt 2012;

53: 6004-10.

B35. Wu DZ, Chang FX, Wu L, et al. Visual rehabilitation in low vision patients with age-related macular degeneration. Eye Sci 1991; 7: 143-5.

LOW VISION DEVICES FOR MACULAR DEGENERATION 48

Appendix C. The individual assessments, and final agreed decision, from two reviewers on the thirty-five included studies, using the Joanna Briggs Critical Appraisal Tools for Quasi-Experimental Studies.

Checklist criteria:

1. Is it clear in the study what is the ‘cause’ and what is the ‘effect’ (i.e. there is no confusion about which variable comes first)? 2. Were the participants included in any comparisons similar? 3. Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest? 4. Was there a control group? 5. Were there multiple measurements of the outcome both pre and post the intervention/exposure? 6. Was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analyzed? 7. Were the outcomes of participants included in any comparisons measured in the same way? 8. Were outcomes measured in a reliable way? 9. Was appropriate statistical analysis used?

Criteria 1 2 3 4 5 6 7 8 9 Studies R1 R2 A R1 R2 A R1 R2 A R1 R2 A R1 R2 A R1 R2 A R1 R2 A R1 R2 A R1 R2 A Altinbay et al. (2016)C1 Y Y Y Y Y Y Y Y Y N N N Y Y Y Y Y Y Y Y Y NA NA NA Y Y Y Amore et al. (2016)C2 U Y Y Y Y Y U Y Y N N N Y Y Y Y Y Y U Y Y NA NA NA Y Y Y Ballinger et al. (2000)C3 Y Y Y Y Y Y U U U N N N Y Y Y Y Y Y U Y Y NA NA NA U Y Y Bowers et al. (2007)C4 N U N Y Y Y Y Y Y N N N N U N Y Y Y Y Y Y NA NA NA Y Y Y Calabrese et al. Y Y Y Y Y Y Y Y Y N N N Y Y Y Y Y Y Y Y Y NA NA NA Y Y Y (2018)C5 Cheong et al. (2002)C6 Y Y Y Y Y Y Y Y Y N N N Y Y Y N U N Y Y Y NA NA NA Y Y Y Cheong et al. (2009)C7 Y Y Y Y Y Y Y Y Y N N N Y Y Y Y Y Y Y N Y NA NA NA Y Y Y Cheong et al. (2005)C8 Y Y Y Y Y Y U Y Y Y Y Y Y Y Y Y U Y Y Y Y NA NA NA Y Y Y Culham et al. (2004)C9 Y Y Y Y Y Y U Y Y N N N Y Y Y Y Y Y Y Y Y NA NA NA Y Y Y DeCarlo et al. (2012)C10 U Y U Y Y Y U U U N N N Y Y Y N N N U U U NA NA NA Y Y Y Eklund and Dahlin- Y Y Y Y Y Y U Y U Y Y Y N Y N Y Y Y U Y U NA NA NA Y Y Y Ivanoff (2007)C11 Frennesson et al. Y Y Y Y Y Y U N U N N N Y Y Y Y Y Y N Y N NA NA NA U Y U (1995)C12

Gill et al. (2013)C13 Y Y Y Y Y Y Y Y Y U Y U N Y Y Y Y Y Y Y Y NA NA NA U Y U LOW VISION DEVICES FOR MACULAR DEGENERATION 49

Goodrich and Kirby Y Y Y Y Y Y N U U N N N Y Y Y Y Y Y Y Y Y NA NA NA Y Y Y (2001)C14 Haji et al. (2014)C15 Y Y Y Y Y Y Y U U N N N Y Y Y Y Y Y U Y Y NA NA NA U Y U Harper et al. (1999)C16 NA Y NA Y Y Y U Y U N N N Y Y Y Y Y Y U Y U NA NA NA Y Y Y Huber et al. (2008)C17 Y Y Y Y Y Y U Y Y N N N Y Y Y N Y Y Y Y Y NA NA NA Y Y Y Khan et al. (2002)C18 U Y Y Y Y Y N U U N N N Y U Y U Y U Y Y Y NA NA NA Y Y Y Latham (2018)C19 Y Y Y U Y Y Y Y Y N N N Y Y Y Y Y Y Y Y Y NA NA NA Y Y Y Leat et al. (2017)C20 U Y Y Y Y Y N U U Y Y Y Y Y Y Y Y Y Y Y Y NA NA NA Y Y Y Morrice et al. (2007)C21 Y Y Y Y Y Y Y U U N N N Y Y Y Y Y Y Y N Y NA NA NA Y Y Y Moshtael et al. Y Y Y Y Y Y Y U U N N N Y Y Y Y Y Y Y Y Y NA NA NA Y Y Y (2019)C22 Nguyen et al. (2007)C23 U Y U Y Y Y N Y Y N N N Y Y Y Y Y Y Y Y Y NA NA NA Y Y Y

Nguyen and Trauzettel- Y Y Y Y Y Y U U U N N N Y Y Y U Y Y Y N N NA NA NA Y Y Y Klosinski (2009)C24

Nguyen et al. (2009)C25 Y Y Y Y Y Y U U U N N N Y Y Y U Y Y Y Y Y NA NA NA Y Y Y

Nilsson (1990)C26 Y Y Y U Y Y Y U U Y N Y Y Y Y U Y Y Y Y Y NA NA NA Y Y Y Nilsson and Nilsson Y Y Y U Y U U Y U N N N Y Y Y Y Y Y U Y Y NA NA NA U Y U (1986)C27

Reeves et al. (2004)C28 U Y Y Y Y Y U U U N Y Y Y Y Y Y Y Y N Y N NA NA NA U Y Y

Rishi et al. (2017)C29 Y Y Y Y Y Y U U U N N N Y Y Y Y Y Y Y Y Y NA NA NA Y Y Y

Tejeria et al. (2002)C30 Y Y Y Y Y Y Y U U N N N Y Y Y Y Y Y Y Y Y NA NA NA Y Y Y Virtanen and Y Y Y Y Y Y U U U N N N N N N Y Y Y U U U NA NA NA Y Y Y Laatikainen (1991)C31

Walker et al. (2016)C32 Y Y Y Y Y Y Y U U N N N Y Y Y Y Y Y Y Y Y NA NA NA Y Y Y

Watson et al. (2004)C33 Y Y Y Y Y Y Y Y Y N N N Y Y Y Y Y Y Y Y Y NA NA NA Y Y Y

Watson et al. (2012)C34 Y Y Y Y Y Y Y U U N N N Y Y Y Y Y Y Y Y Y NA NA NA Y Y Y

Wu et al. (1991)C35 Y Y Y Y Y Y U U U N N N Y Y Y Y Y Y U Y U NA NA NA U Y U Note: R1=reviewer 1; R2=reviewer 2; Joanna Briggs answer options: A=agreed decision; Y=yes; N=no; U=unclear; NA=not applicable LOW VISION DEVICES FOR MACULAR DEGENERATION 50

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