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Figure.  Flowchart for Identification and Prioritization of Clinical Questions
Flowchart for Identification and Prioritization of Clinical Questions

ACRC indicates Atlantic Coast Retina Conference; ASRS, American Society of Retinal Specialists; MD, macular degeneration; and PPP, preferred pratice pattern.

Table 1.  Prioritization of 17 Highly Important Clinical Questions Associated With the Management of Age-Related Macular Degeneration (AMD)
Prioritization of 17 Highly Important Clinical Questions Associated With the Management of Age-Related Macular Degeneration (AMD)
Table 2.  Characteristics of the Clinical Survey Respondents
Characteristics of the Clinical Survey Respondents
Table 3.  Characteristics of Patient Survey Respondents
Characteristics of Patient Survey Respondents
Table 4.  Prioritization of Patient-Important Outcomes for Research in Age-Related Macular Degeneration (AMD)
Prioritization of Patient-Important Outcomes for Research in Age-Related Macular Degeneration (AMD)
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Paulus  YM, Jefferys  JL, Hawkins  BS, Scott  AW.  Visual function quality of life measure changes upon conversion to neovascular age-related macular degeneration in second eyes.  Qual Life Res. 2017;26(8):2139-2151. doi:10.1007/s11136-017-1547-zPubMedGoogle ScholarCrossref
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Williamson  PR, Altman  DG, Bagley  H,  et al.  The COMET Handbook: version 1.0.  Trials. 2017;18(suppl 3):280. doi:10.1186/s13063-017-1978-4PubMedGoogle ScholarCrossref
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Li  T, Ervin  AM, Scherer  R, Jampel  H, Dickersin  K.  Setting priorities for comparative effectiveness research: a case study using primary open-angle glaucoma.  Ophthalmology. 2010;117(10):1937-1945. doi:10.1016/j.ophtha.2010.07.004PubMedGoogle ScholarCrossref
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Le  JT, Hutfless  S, Li  T,  et al.  Setting priorities for diabetic retinopathy clinical research and identifying evidence gaps.  Ophthalmol Retina. 2017;1(2):94-102. doi:10.1016/j.oret.2016.10.003PubMedGoogle ScholarCrossref
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Saldanha  IJ, Dickersin  K, Hutfless  ST, Akpek  EK.  Gaps in current knowledge and priorities for future research in dry eye.  Cornea. 2017;36(12):1584-1591.PubMedGoogle ScholarCrossref
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Lindsley  K, Li  T, Ssemanda  E, Virgili  G, Dickersin  K.  Interventions for age-related macular degeneration: are practice guidelines based on systematic reviews?  Ophthalmology. 2016;123(4):884-897. doi:10.1016/j.ophtha.2015.12.004PubMedGoogle ScholarCrossref
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American Academy of Ophthalmology Retina/Vitreous Panel. Preferred Practice Pattern Guidelines: Age-Related Macular Degeneration. San Francisco, CA: American Academy of Ophthalmology;2015. http://www.aao.org/ppp.
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American Academy of Ophthalmology Retina/Vitreous Panel. Preferred Practice Pattern Guidelines: Age-Related Macular Degeneration. San Francisco, CA: American Academy of Ophthalmology;2014. http://www.aao.org/ppp.
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Original Investigation
November 2018

Evaluation of Clinical Questions and Patient-Important Outcomes Associated With the Treatment of Age-Related Macular Degeneration

Author Affiliations
  • 1Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 2Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
  • 3Division of Gastroenterology & Hepatology, Johns Hopkins School of Medicine, Baltimore, Maryland
  • 4Department of Ophthalmology, Johns Hopkins School of Medicine, Baltimore, Maryland
  • 5American Society of Retina Specialists, Chicago, Illinois
  • 6MD (Macular Degeneration) Support, Grandview, Missouri
  • 7Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
  • 8Preferred Practice Pattern Retina/Vitreous Panel and Secretary for Quality of Care, American Academy of Ophthalmology, San Francisco, California
  • 9Quality and Data Science, American Academy of Ophthalmology, San Francisco, California
  • 10Reviews Editor, JAMA Ophthalmology
JAMA Ophthalmol. 2018;136(11):1217-1225. doi:10.1001/jamaophthalmol.2018.3456
Key Points

Question  What are the high-priority clinical questions and patient-important outcomes associated with the treatment of age-related macular degeneration?

Findings  In this cross-sectional survey of 124 health care professionals and 46 patients with age-related macular degeneration, respondents named the high-priority clinical questions associated with treatment of age-related macular degeneration; respondents, professionals, and patients agreed on 12 questions, and patients with age-related macular degeneration identified 6 highly important outcomes balanced between intended effects of treatment (eg, slowing vision loss) and adverse events (eg, retinal hemorrhage).

Meaning  The results from this cross-sectional survey may inform future age-related macular degeneration research and clinical care.

Abstract

Importance  Identifying and prioritizing unanswered clinical questions may help to best allocate limited resources for research associated with the treatment of age-related macular degeneration (AMD).

Objective  To identify and prioritize clinical questions and outcomes for research associated with the treatment of AMD through engagement with professional and patient stakeholders.

Design, Setting, and Participants  Multiple cross-sectional survey questions were used in a modified Delphi process for panel members of US and international organizations, the American Academy of Ophthalmology (AAO) Retina/Vitreous Panel (n=7), health care professionals from the American Society of Retinal Specialists (ASRS) (n=90), Atlantic Coast Retina Conference (ACRC) and Macula 2017 meeting (n=34); and patients from MD (Macular Degeneration) Support (n=46). Data were collected from January 20, 2015, to January 9, 2017.

Main Outcomes and Measures  The prioritizing of clinical questions and patient-important outcomes for AMD.

Results  Seventy clinical questions were derived from the AAO Preferred Practice Patterns for AMD and suggestions by the AAO Retina/Vitreous Panel. The AAO Retina/Vitreous Panel assessed all 70 clinical questions and rated 17 of 70 questions (24%) as highly important. Health care professionals assessed the 17 highly important clinical questions and rated 12 of 17 questions (71%) as high priority for research to answer; 9 of 12 high-priority clinical questions were associated with aspects of anti–vascular endothelial growth factor agents. Patients assessed the 17 highly important clinical questions and rated all as high priority. Additionally, patients identified 6 of 33 outcomes (18%) as most important to them (choroidal neovascularization, development of advanced AMD, retinal hemorrhage, gain of vision, slowing vision loss, and serious ocular events).

Conclusions and Relevance  Input from 4 stakeholder groups suggests good agreement on which 12 priority clinical questions can be used to underpin research related to the treatment of AMD. The 6 most important outcomes identified by patients were balanced between intended effects of AMD treatment (eg, slowing vision loss) and adverse events. Consideration of these patient-important outcomes may help to guide clinical care and future areas of research.

Introduction

Age-related macular degeneration (AMD) is the leading cause of uncorrectable vision loss in adults 50 years and older in the United States.1 Vision loss due to AMD, which ultimately affects central vision, is associated with poor quality of life and a decreased sense of independence in affected individuals.2 Similar to clinical measures, outcomes that have been named as important by patients should be validated through research.3 Patient perspective, clinical expertise, and scientific evidence form the triad of evidence-based medicine; thus these viewpoints should be considered together when setting a research agenda and determining outcomes to be examined in research.4

Randomized clinical trials (RCTs) and systematic reviews of RCTs are considered to provide the highest level of evidence to determine the effectiveness of clinical interventions.5 Resources are insufficient to conduct RCTs and systematic reviews on all possible research questions.6 Thus, establishing a framework for identifying important unanswered clinical questions would help funders and researchers to prioritize trials and systematic reviews to be conducted.

The overall objective of this study was to identify and prioritize clinical questions and patient-important outcomes associated with the treatment of AMD by adapting a priority-setting framework used for other eye conditions.7-11 The process begins by identifying treatment recommendations from clinical practice guidelines and translating each treatment recommendation into an answerable clinical question. In a previous study,12 evidence gaps were identified by assessing the evidence cited to support each treatment recommendation and mapping the clinical questions to existing reliable systematic reviews for treatment recommendations extracted from the 2015 American Academy of Ophthalmology (AAO) Preferred Practice Pattern (PPP) for the management of AMD.13 In this study, multiple stakeholders, including clinical practice guideline developers, health care professionals, and patients, prioritized the importance of research to answer each clinical question in light of the available evidence.

Methods

This study used a modified Delphi process to identify and prioritize clinical research questions and patient-important outcomes associated with the treatment of AMD in 4 steps: (1) derive clinical questions from clinical practice guidelines and specialists in AMD; (2) survey clinical practice guideline developers to identify the most important clinical questions for research to answer; (3) survey retina experts and health care professionals to prioritize the order in which the most important clinical questions should be addressed by research; and (4) survey patients to prioritize the most important clinical questions and outcomes from their perspective (Figure).

This study was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board, Baltimore, Maryland. Per direction from the institutional review board, the survey included the statement that completing the survey was also providing informed consent. We did not collect identifiable data from any survey participant and all responses remain anonymous. eAppendix 1 in the Supplement includes protocol and amendments.

Step 1: Derive Clinical Questions From Clinical Practice Guidelines and Specialists in AMD

We identified treatment recommendations in the 2014 and 2015 AAO clinical practice guidelines, known as Preferred Practice Pattern (PPP), for management of AMD.13,14 Two individuals (B.S.H. and K.B.L. for 2014 PPP and K.B.L. and S.H. for 2015 PPP) independently reviewed and extracted every statement that could be considered a treatment recommendation published in the PPP guideline. We formulated each recommendation into an answerable clinical question using the PICO (participant, intervention, comparison, and outcome) format. We consulted with AMD specialists (1 member of ACRC and Macula 2017, Neil M. Bressler, MD, and 1 of us, T.W.O.) who had expertise both in the management of AMD and in forming answerable clinical questions to confirm that our restatements were accurate and adding other clinical questions that were not addressed directly in the PPP guideline.

Step 2: Identify Highly Important Clinical Questions

We conducted a 2-round, web-based, cross-sectional, modified Delphi consensus survey.15 We asked each panel member to assign a rating to each clinical question derived from the PPP on a scale of 0 to 10, with 10 indicating highly important and 0 indicating not important at all. Panel members also had an option to assign a score of “no judgment.” At each round, panel members could enter comments and suggest new clinical questions.

We administered the first round of the survey in 2 stages because the AAO PPP published an update during the first survey period (January 2015). From January to February 2015, the 7-member panel rated 46 clinical questions derived from the 2014 AAO PPP on the management of AMD. We used Survey Monkey (http://www.surveymonkey.com) in the first part of round 1; we used Qualtrics (http://www.qualtrics.com) for all subsequent online surveys. One panel member withdrew from the panel between the first and second part of round 1 and was not replaced. In the second part of round 1 (March 2016), the 6-member panel rated 24 additional clinical questions as a continuation of the first round of the survey, 19 derived from the 2015 AAO PPP and 5 contributed by the panel members in the first stage. In the 2 parts of round 1, panel members prioritized a total of 70 clinical questions.

In round 2 of the survey, conducted from June through August 2016, we provided the 6 panel members the median score for each clinical question from the first round of the survey. We asked them to rate the 70 clinical questions again, taking into account the median scores from the first round.

After the second round was completed, we grouped clinical questions into 3 prespecified tiers based on the median scores after the second round (tier 1, median score of 7-10; tier 2, median score of 4-6.9, and tier 3, median score of 0 to 3.9). We considered tier 1 questions to represent highly important clinical research questions. The rationale for asking the panel to identify the most important clinical questions was to reduce the number of clinical questions so that the prioritization surveys could be completed in 15 minutes or less.

Step 3: Prioritize Clinical Questions by Health Care Professionals

To prioritize the tier 1 clinical questions, we surveyed members of the American Society of Retinal Specialists (ASRS) and attendees of the Atlantic Coast Retina Conference (ACRC) and Macula 2017 meetings. Survey participants rated each tier 1 clinical question on a scale of 0 to 10, with 10 indicating the highest priority and 0 indicating not a priority at all (eAppendix 3 in the Supplement). Survey participants also had an option to assign a score of “no judgment” and to submit additional clinical questions important to them. Additionally, we asked survey participants to provide demographic and professional information.

In partnership with ASRS, the survey was announced and first made available at the ASRS exhibitor booth on Retina Subspecialty Day at the AAO Annual Meeting in Chicago, Illinois, on October 14, 2016. The survey was available online via ASRS listserv until December 19, 2016; invitations and reminders to complete the survey were sent to the membership via ASRS’s Retina FYI monthly e-newsletter (October, November, and December 2016). The ASRS listserv included 2719 email addresses.

We surveyed attendees of the ACRC and Macula 2017 meeting, held January 5-7, 2017, in Baltimore, Maryland. The survey, administered on paper, included the same questions as those posed to ASRS, with an additional question that asked whether the participant had completed the online survey. We distributed 86 surveys to attendees from the registration table. We collected completed surveys through January 9, 2017.

Step 4: Prioritize Clinical Questions and Outcomes by Patients

The online MD (Macular Degeneration) Support is a nonprofit organization established to educate and support individuals affected by macular degeneration. Survey participants rated each tier 1 clinical question on a scale of 0 to 10, with 10 indicating the highest priority and 0 indicating not a priority at all. In addition to rating the tier 1 clinical questions, survey participants ranked the importance of outcomes related to the management of AMD using 4 categories: most important, moderately important, least important, and unsure (no judgment). We identified the outcomes to be ranked based on common AMD-related outcomes assessed in published RCTs and systematic reviews.16,17 We considered outcomes ranked as “most important” by 70% or more respondents as highly important and those scored as “most important” by 15% or fewer respondents as not highly important.18 We asked participants to record any clinical questions or outcomes of importance to them that were not included in the survey. We also asked broad, nonidentifying questions about the respondents’ AMD status, such as stage of AMD.

The patient survey was available online from October 13, 2016, until December 19, 2016. The MD Support online forum consists of 385 listserv members and 451 people registered for automatic notices on the website. An unknown number of people are registered to both lists; thus, we considered the forum to include a maximum of 836 unique email addresses.

We calculated the median and interquartile range for each clinical question from each prioritization survey. We considered clinical questions with a median score of 7 or higher to represent high-priority clinical questions for research to answer. We compared scores by cohort of stakeholders (ie, ASRS, ACRC and Macula 2017, and MD Support). Data were collected from January 20, 2015, to January 9, 2017.

Results

In total, we identified 70 clinical questions associated with the management of AMD (eAppendix 1 in the Supplement). Of the 70 clinical questions, 17 involved anti–vascular endothelial growth factor (anti-VEGF) agents; 13 photodynamic therapy; 8 laser photocoagulation; 8 antioxidant vitamin and mineral supplements; and 24 were related to other treatment modalities.

The AAO Retina/Vitreous Panel rated 17 of 70 clinical questions (24%) as tier 1 (ie, highly important) (Figure; eAppendix 2 in the Supplement). No clinical question changed tiers between round 1 and round 2 of the survey. Nine of the 17 tier 1 clinical questions (53%) related to anti-VEGF agents, 4 to antioxidant vitamin and mineral supplements (24%), and 1 each to photodynamic therapy, smoking cessation, self-monitoring, and surgery for cataract in eyes with AMD (Table 1). Six of the 7 panel members reported no conflicts of interest.

From invitations sent to 2719 email addresses in the ASRS listserv, 106 ASRS members (4%) accessed the online prioritization survey and 90 of 106 members (85%) participated in the survey. Health care professionals assessed the 17 highly important clinical questions and rated 12 of 17 questions (71%) as high priority for research to answer. Nine of the 12 high-priority clinical questions were associated with aspects of anti-VEGF agents. We distributed 86 paper surveys to ACRC and Macula 2017 attendees and 34 of 86 surveys (40%) were returned. None of the ACRC and Macula 2017 respondents reported completing the online survey. In total, the prioritization surveys were viewed by 192 health care professionals and 124 of 192 professionals (65%) responded to at least 1 survey question.

There were similarities and differences among participants in the ASRS and ACRC and Macula 2017 cohorts (Table 2). Most respondents were US-based ophthalmologists specializing in the retina, had affiliation with at least one professional society, had experience working on RCTs, used systematic reviews for making treatment decisions, and reported no conflicts of interest. Many ASRS participants (61 of 90 [68%]) were self-employed or in private practice, whereas most ACRC and Macula 2017 participants (22 of 34 [65%]) were affiliated with academic centers. Eleven percent of ASRS participants (10 of 90) reported that 1% to 25% of their patients had AMD compared with 44% of ACRC and Macula 2017 participants (15 of 34); 54% of ASRS participants (49 of 90) reported that 26% to 50% of their patients had AMD compared with 18% of ACRC and Macula 2017 participants (6 of 34). Among ASRS respondents, 57% (51 of 90) were not members of any formal research group compared with 74% of ACRC and Macula 2017 respondents (25 of 34).

Of the 17 tier 1 clinical questions, there was general agreement among respondents from the health care professional groups surveyed (Table 1). Both groups rated all 9 of the tier 1 clinical questions associated with anti-VEGF treatments as high priority. Two additional clinical questions were suggested by survey participants: (1) Which types of drug delivery systems are effective and safe? (2) Which interventions are effective and safe for treating or preventing geographic atrophy?

Of the 836 email addresses in the MD Support forum, 56 patients (7%) accessed the online prioritization survey and 46 of 56 patients (82%) participated in the survey. Half of the patients who responded had wet AMD (Table 3). Of 35 respondents with AMD, most had been diagnosed at least 1 year earlier, were women, were aged 70 years or older, and lived in the United States.

Participants from MD Support rated all 17 tier 1 clinical questions as high priority (Figure), with 12 of 17 questions given a median score of 10 (eAppendix 2 in the Supplement). Survey participants suggested 4 additional clinical questions that were not included in the survey:

  1. Is gene therapy (or stem cell therapy) effective in treating AMD?

  2. Is the intraocular miniature telescope an effective treatment for AMD?

  3. Are cholesterol-lowering diets effective in preventing or reducing AMD-related drusen?

  4. What types of education improve living with AMD (eg, online support groups, communication with health care professionals)?

Six of 33 outcomes were identified as most important: choroidal neovascularization, development of advanced AMD, any retinal hemorrhage occurring with choroidal neurovascularization, gain of vision, vision loss, and serious ocular events (eg, endophthalmitis). Eight outcomes were scored as not highly important: copper deficiency anemia, cosmetic effects (eg, yellowing of skin), depression, falls, hospitalizations, lung cancer among smokers, visual hallucination, and vitreous floaters (Table 4). No additional outcomes were suggested by survey participants.

Discussion

The results of this priority-setting study suggest that research related to anti-VEGF treatments for AMD remains a key area of interest for multiple stakeholder groups. Nine of 17 highly important clinical questions identified by the AAO Retina/Vitreous Panel were associated with aspects of anti-VEGF treatments, all of which were rated as high priority by all prioritization survey cohorts. Previous research evaluating the reliability of systematic reviews of interventions for AMD also showed that anti-VEGF agents were the most common treatment modality evaluated by systematic reviewers.12 Although many high-quality RCTs and systematic reviews have addressed the effectiveness and safety of intravitreous anti-VEGF injections for AMD, new questions have emerged now that they have become the standard of care for neovascular AMD, concerning how frequently injections should be administered, the long-term (≥10 years) effects of these injections, and other possible drug delivery options.

Health care professionals and patients rated clinical questions addressing both effectiveness and safety as highly important. Furthermore, the highly important outcomes identified by patients in this study were balanced between intended effects of AMD treatment (eg, slowing vision loss) and adverse events (eg, retinal hemorrhage). This balance suggests research that examines potential benefits and harms together (eg, trade-off analysis) as an area for future investigation.

Methodologic Considerations

In this study, we evaluated a single method for prioritizing clinical research; another method may have led to other topics given priority. A priority-setting project in the United Kingdom that used a focus group format identified 29 priority questions related to AMD.19 However, their questions included question types not limited to treatment, such as “What is the cause of AMD?” and questions too broad for an RCT to address, such as “Can a treatment to stop dry AMD progressing and/or developing into the wet form be devised?” Our project was designed to include and prioritize only clinical questions for specific treatments.

As part of the study design, we asked the AAO Retina/Vitreous Panel to narrow the list of 70 clinical questions that we identified to a shortened list of highly important (tier 1) clinical questions. The rationale was to reduce the number of clinical questions for the larger groups to prioritize. However, even with a shortened survey, the response rate was low for all groups surveyed.

Patients rated all 17 clinical questions identified as highly important by the AAO Retina/Vitreous Panel as high priority, compared with 12 of 17 rated as high priority by both health care professional groups. When asked to rank the importance of outcomes by allocating outcomes into 1 of 4 categories, patients distinguished 6 highly important outcomes and 8 not so important outcomes among 33 outcomes assessed. Other patient-focused research has shown that patients tend to score all items as high priority when using rating scales, such as Likert scales.20 For prioritization research, asking participants to rank items rather than rating them independently may elicit clear patient preferences.

We identified at least 12 high-priority clinical research questions. Survey participants suggested additional areas of interest, such as alternative drug delivery systems, interventions for treating or preventing geographic atrophy, and effects of gene therapy. In a 2015 study of evidence used to underpin clinical practice guidelines, reliable systematic reviews were cited to support 15 of 35 treatment recommendations in the 2015 AAO PPP for AMD.12 Nine of the high-priority clinical questions identified by this prioritization project map to the 15 treatment recommendations with reliable systematic reviews available, suggesting that even with existing high-quality evidence, some uncertainty may remain as to whether a clinical question has been answered. For the remaining 8 highly important clinical questions identified by the AAO Retina/Vitreous Panel, no reliable systematic review had been identified, suggesting research areas with evidence gaps.

Limitations

A potential limitation to our framework is that we derived our initial set of clinical questions from clinical practice guidelines concurrently with the request for new clinical questions. Although evidence-based clinical practice guidelines may reflect the current state of prevention, screening and therapy from multiple stakeholder groups,4 they may not anticipate new treatments or areas of research. To address this issue, we consulted with members of the AAO Retina/Vitreous Panel to add relevant clinical questions to our initial set and provided survey participants opportunities to suggest additional research questions at each stage of the process.

Conclusions

The 6 highly important outcomes targeted by patients should be considered in the discussion of core outcome sets for studies that evaluate the treatment of AMD. Choroidal neovascularization and visual acuity are outcomes that have been noted frequently in outcome research related to AMD; however, retinal hemorrhage has been considered less frequently by clinicians and researchers.17,21,22 While we cannot assume that patients understand the AMD process, all patient participants were members of MD Support, an education-oriented support community for individuals with AMD. Further research could survey AMD patients more generally to see if there are different priorities or outcome concerns based on different levels of understanding of AMD.

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Article Information

Corresponding Author: Kristina B. Lindsley, MS, Department of Epidemiology, University Medical Center Utrecht, Huispost Str 6.131, PO Box 85500, 3508 GA Utrecht, the Netherlands (k.b.lindsley@umcutrecht.nl).

Accepted for Publication: June 4, 2018.

Published Online: August 16, 2018. doi:10.1001/jamaophthalmol.2018.3456

Author Contributions: Ms Lindsley had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Lindsley, Hutfless, Dickersin.

Acquisition, analysis, or interpretation of data: Lindsley, Hutfless, Blim, Hawkins, Roberts, Olsen, Lum.

Drafting of the manuscript: Lindsley, Roberts.

Critical revision of the manuscript for important intellectual content: Lindsley, Hutfless, Hawkins, Blim, Olsen, Lum, Dickersin.

Statistical analysis: Lindsley, Dickersin.

Administrative, technical, or material support: Lindsley, Hawkins, Blim, Lum.

Supervision: Lindsley.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Ms Lindsley and Drs Hawkins and Dickersin are contributors to Cochrane and the Cochrane Eyes and Vision Group. Dr Olsen is the founder of iMacular Regeneration, LLC (nothing related to any subject discussed herein). No other disclosures were reported.

Funding/Support: This research was funded by National Eye Institute grant 1 U01 EY020522, National Institutes of Health, Department of Health and Human Services.

Role of the Funder/Sponsor: The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Dr Dickersin is Reviews Editor of JAMA Ophthalmology, but she was not involved in any of the decisions regarding review of the manuscript or its acceptance.

Additional Contributions: Ava Bittner, OD, PhD, FAAO (formerly employed at Johns Hopkins University), helped to identify survey groups, and Jennifer Harris, MS, and Greg Maltz, BS (American Academy of Ophthalmology), Neil M. Bressler, MD (the Atlantic Coast Retina Conference and Macula 2017; editor in chief, JAMA Ophthalmology), and Lydia Steck, MSJ (American Society of Retina Specialists), distributed the surveys. We thank the members of the AAO Retina/Vitreous Preferred Practice Panel, American Society of Retina Specialists, Atlantic Coast Retina Conference, Macula meeting, and MD Support who participated in the surveys. Lotty Hooft, PhD, and Rob Scholten, PhD (Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands), provided commentary. No compensation was received.

References
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Paulus  YM, Jefferys  JL, Hawkins  BS, Scott  AW.  Visual function quality of life measure changes upon conversion to neovascular age-related macular degeneration in second eyes.  Qual Life Res. 2017;26(8):2139-2151. doi:10.1007/s11136-017-1547-zPubMedGoogle ScholarCrossref
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