{"paper_id":"a13fea7f-ef71-4d17-a3f4-efcaefab98fb","body_text":"The Royal College of Ophthalmologists National Ophthalmology Database Age-related Macular Degeneration Audit: Report 1, Associations with socio-economic deprivation in neovascular age-related macular degeneration | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article The Royal College of Ophthalmologists National Ophthalmology Database Age-related Macular Degeneration Audit: Report 1, Associations with socio-economic deprivation in neovascular age-related macular degeneration Riddhi Shenoy, Mable Monachan, Marta Gruszka-Goh, Martin McKibbin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7417262/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Mar, 2026 Read the published version in Eye → Version 1 posted 9 You are reading this latest preprint version Abstract Background: Early diagnosis and treatment of neovascular age-related macular degeneration (NvAMD) improve vision outcomes. This analysis investigates associations of English indices of multiple deprivation 2019 (IMD2019) with baseline characteristics, key care processes and visual acuity (VA) outcomes for NvAMD in the National Ophthalmology Database (NOD). Methods : Eligible eyes started treatment for NvAMD in England between 01/04/2020 and 31/03/2023. Participating centres with ≥25 eyes with baseline VA and IMD2019 data were included. Results: Eligible for analysis were 48 583 eyes from 60 English centres. Median age at start of treatment ranged from 79-82 years between deciles 1 (most deprived) to 10 (least deprived). Median baseline VA ranged from 56 to 60 ETDRS letters for deciles 1 to 10. After one year of treatment (-28 to +84 days), the median number of injections administered ranged from 7-8 for deciles 1 to 10. Loss to follow-up was observed in 13.7% in decile 1, and 11.8% in decile 10. Median VA ranged from 61 to 65 ETDRS letters for deciles 1 to 10. A good VA outcome (≥70 ETDRS letters) was achieved by 35.9% of eyes in decile 1 and 45.5% in decile 10. A poor VA outcome, (decrease of ≥10 ETDRS letters from baseline) was experienced by 18.4% of eyes in decile 1 and 14.5% in decile 10. Conclusions: Patients starting NHS-funded treatment in England for NvAMD and living in areas of higher socio-economic deprivation were typically younger, had lower baseline acuity and achieved worse VA outcomes than those from lower deprivation areas, despite receiving similar treatment. Health sciences/Health care/Public health/Epidemiology Scientific community and society/Scientific community Figures Figure 1 Figure 2 Summary Box What was known before Reducing inequity in eye health is a national priority and links between socioeconomic deprivation and advanced eye disease are already described. Few studies in the UK have investigated associations between socio-economic deprivation and baseline characteristics, age, key care processes and visual acuity outcomes after treatment for neovascular age-related macular degeneration. What this study adds Socio-economic deprivation is associated with age and visual acuity at presentation, key care processes and visual acuity outcomes after NHS-funded treatment in England for neovascular age-related macular degeneration. Further analysis is required to investigate if socioeconomic deprivation is independently associated with baseline visual acuity and outcomes after treatment. Introduction Age related macular degeneration (AMD) is a chronic progressive eye condition and the leading cause of irreversible visual impairment in older people in developed countries, with 200 million people estimated to have AMD worldwide in 2020 ( 1 , 2 ). Neovascular AMD (NvAMD) is an advanced form of AMD characterised by macular neovascularisation that can cause rapid central vision loss. Early diagnosis and treatment of NvAMD with intravitreal inhibition of vascular endothelial growth factor (VEGF) improves vision outcomes( 3 – 5 ). Notably, along with age, visual acuity (VA) at presentation has been shown to be one of the strongest predictors of long-term vision outcomes ( 6 , 7 ). Inequality in eye health is increasingly being identified across the conditions most responsible for visual impairment, with socioeconomic deprivation in the UK associated with more advanced eye disease and lower uptake of optometry services( 8 – 11 ). Existing evidence for the association between deprivation and AMD is inconsistent, though real-world data largely indicates disparities by socioeconomic status, with lower baseline vision and greater prevalence of AMD observed amongst those living in areas of greatest deprivation, and subsequent poorer visual acuity outcomes following treatment ( 12 – 15 ). This study reports analysis of data supplied to the Royal College of Ophthalmologists (RCOphth) National Ophthalmology Database (NOD) AMD Audit, investigating associations of deprivation with baseline characteristics, key care processes and VA outcomes in NvAMD. Methods The RCOphth NOD National AMD Audit is open to centres performing NHS funded treatment of NvAMD within the UK and Channel Islands. The data is collected as part of routine clinical care on electronical medical record systems (EMR) or in-house databases and submitted annually for eyes starting treatment for NvAMD. Further information on the RCOphth NOD AMD Audit can be found on the audit website ( www.nodaudit.org.uk ). Eligible for analysis were NHS-funded intravitreal anti-VEGF treatments submitted to RCOphth NOD administered in English centres with at least 25 treated eyes between 01/04/2020 and 31/03/2023 (supplementary file 1 for list of participating centres). Inclusion criteria for eyes required recording of baseline VA and the English Indices of Multiple Deprivation (IMD) 2019 for each patient( 16 ). (IMD is a percentile rank estimate of relative deprivation that ranks neighbourhoods in England across seven domains (income, employment, education, health, crime, housing and living environment). Due to different measures of deprivation used in Scotland, Wales and Ireland, only data from England were analysed.) During data extraction, IMD deciles were matched to the patient’s post code, from decile 1 (most deprived) to decile 10 (least deprived), and transferred to the RCOphth NOD without the patient’s postcode. This analysis reports outcomes over the first 12 months of eyes commencing treatment in the 2020–2022 NHS years. Outcome measures VA at baseline and after 12 months of treatment (-28 to + 84 days) was recorded in ETDRS letters. A change of five ETDRS letters is equivalent to 0.10 LogMAR unit. A good VA outcome at 12 months was defined as ≥ 70 ETDRS letters. A poor VA outcome at 12 months was defined as a decrease of ≥ 10 ETDRS letters from baseline. Eyes with a baseline VA ≤ 25 ETDRS letters were excluded from poor VA outcome analysis (supplementary Fig. 1). Loss to follow-up was defined as eyes for which no clinical information was available at 12 months (+ 84 days) following treatment commencement. All eyes with VA data or injection data at one year were considered to have completed follow-up. Statistical analysis All analyses were performed using STATA 18 (StataCorp. 2023. Stata Statistical Software: Release 18. College Station, TX: StataCorp LLC). Results Baseline characteristics Eligible for analysis were 48 583 eyes of 42 043 patients from 60 English participating centres (including 47 NHS Trusts and 13 independent sector treatment centres). Anti-VEGF injections were administered to 24 001 (49.4%) left eyes and 24 582 (50.6%) right eyes. Of 42 043 patients, 25 240 (60.0%) were female, 15 514 (36.9%) were male, and the gender was not stated for 1 289 (3.1%) patients. The majority of the sample consisted of 33 161 (68.3%) first treated eyes, of which the median age at start of treatment was 81 years (IQR: 75–86 years). The number of second treated eyes was 9 864 (20.3%) eyes, with a median age at start of treatment of 83 years (IQR: 77–87 years). Immediate sequential bilateral intravitreal treatment (ISBIVT) was given to 5 558 (11.4%) eyes from 2 779 patients, with a median age at start of treatment of 82 years (IQR: 76–87 years). The overall prevalence of diabetes mellitus was 12.7% (5 327 patients). Baseline visual acuity by IMD decile Median age ranged from 79 to 82 years from decile 1 to 10 across the sample (Table 1). The median baseline VA was 60 ETDRS letters (IQR: 45–70 ETDRS letters), ranging from 56 ETDRS letters in decile 1 to 60 ETDRS letters in decile 10 (Fig. 1 ). For first treated eyes, the median baseline VA was 55 ETDRS letters (IQR: 40–68 ETDRS letters), ranging from 55 ETDRS letters in decile 1 to 59 ETDRS letters in decile 10. For second treated eyes, the median baseline VA was 65 ETDRS letters (IQR: 54–71 ETDRS letters), across all deciles. Treated eyes from less deprived deciles were more likely to have baseline VA of ≥ 70 ETDRS letters (29.1%) and less likely to have baseline VA of ≤ 25 ETDRS letters (6.9%) (Table 1). Intravitreal injection pathway uptake by IMD decile The proportion of treated eyes from each IMD decile ranged from 6.6–13.8% for deciles 1–10. All bar 8 centres treated patients from every IMD decile. The median IMD decile from each centre ranged from decile 3 to decile 9 (Fig. 2 ). From the sample, 43 754 (90.1%) of eyes treated in traditional NHS centres, representation from IMD deciles ranged from 6.3% (decile 1) to 13.9% (decile 10). Similarly, in the 4 829 (9.9%) of eyes treated in the independent sector, representation ranged from 10.0% (decile 1) to 13.2% (decile 10). Over the first year of treatment, 48 583 eyes received a total of 345 062 intravitreal injections, of which the proportion ranged from 6.4–13.8% for decile 1–10 (Table 1). The initial loading phase of three anti-VEGF injections was completed within 10 weeks of the first injection by 34 827 (71.7%) eyes (Table 1). The median number of anti-VEGF injections per eye was 7 (IQR: 5–9). There was little variation across IMD deciles for loading phase completion, and the median number of injections during the first year of treatment. Overall, 6 354 (13.1%) eyes were lost to follow up within one year of treatment and the proportion ranged between 13.7–11.8% from deciles 1 to 10, being highest in decile 2 (15.5%) (Table 1). While 456 (7.2%) eyes stopped treatment for clinical reasons, there were no reasons reported for 5 008 (78.8%) eyes lost to follow-up. Visual acuity at 12 months of treatment by IMD decile After one year, VA was recorded for 39 439 (81.2%) eyes from 58 centres. Median VA was 65 ETDRS letters (IQR: 48–75 ETDRS letters), ranging from 61 ETDRS letters (decile 1) to 65 ETDRS letters (decile 10) (Fig. 1 ). The proportion of eyes in which VA improved by > 5 ETDRS letters was 39.1%, by > 10 ETDRS letters was 25% and by > 15 ETDRS letters was 15%, with similar gains across deciles. Good VA (≥ 70 ETDRS letters) at 12 months was achieved by 16,414 (41.6%) eyes, ranging from 35.9% (decile 1) to 45.5% (decile 10) (Table 2). From 39 439 eyes, 36 792 (93.3%) eyes with VA > 25 ETDRS letters from the centres with at least 25 eligible eyes were included. Poor VA outcome at 12 months (≥ 10 ETDRS letters decrease from baseline VA) was experienced for 5 879 (16.0%) eyes, with 18.3% in decile 1 and 14.5% in decile 10, Table 2. The median VA of first treated eyes ranged from 60 to 65 ETDRS letters between deciles 1 to 10. Median VA at 12 months of second treated eyes ranged from 66 to 70 ETDRS letters between deciles 1 to 10 (Supplementary tables 2 and 3) Discussion This review of UK AMD Audit data collected as part of routine care over a 3-year period has found an association between socio-economic deprivation and both baseline and 12-month VA outcomes of NHS-funded treatment for NvAMD in England, despite few differences in the care pathway. A trend towards greater loss to follow up was also observed in the eyes of patients living in areas of higher deprivation. Median baseline VA was lower in patients from the areas of greatest deprivation and 12-month VA outcomes were also worse, despite these patients being younger at the start of treatment. This is in contrast with published studies that generally report better visual outcomes amongst younger patients and may suggest deprivation is associated with more advanced AMD at presentation( 17 , 18 ). This may further indicate barriers to access to diagnosis of AMD in areas of deprivation that are reflected in findings from previous UK studies( 12 , 19 ). One single centre retrospective study in the UK (n = 756) reported that people living in the most deprived areas were significantly more likely, when compared to those from the least deprived areas, to present with severe reduction in acuity, after adjusting for age, gender and distance from treatment centre (OR = 4.07; 95% Cl = 1.50–11.0; P = .006,)( 20 ). Similar associations were reported in another single centre retrospective study in Birmingham (n = 120), but were not found in a similar study in Glasgow (n = 240). However, significant limitations of these retrospective studies include variable measures of deprivation used, variable inclusion of relevant confounders and small sample sizes ( 19 – 21 ). Comparing first and second treated eyes, the trend to poorer baseline VA with greater deprivation was only seen in first treated eyes, suggesting that patients developing NvAMD in their second eye, likely identified through monitoring in secondary care, may not experience the same initial barriers to access. However, the trend to poorer 12-month VA was seen in both first and second treated eyes, suggesting that socio-economic deprivation may have an independent association with acuity outcomes, rather than simply being a surrogate marker of baseline VA. Across all treated eyes, 12-month VA outcomes in this audit remained worse in the eyes of patients from areas of highest deprivation. Barriers to access to primary care, where patients with AMD may first present, may contribute to the association seen with deprivation and worse baseline VA. Analysis of NHS digital data has shown substantial variation in the provision of optometry services in England with much lower rates in more deprived areas versus more affluent areas( 11 ). Inequalities in uptake of eye examinations have also been shown, with analysis of General Ophthalmic Services (GOS) claims for eye examinations in the UK showing people aged over 60 years living in the least deprived areas being 15–71% more likely to access an NHS funded eye examination compared to those in the same age group living in the most deprived areas( 8 , 22 ). Similar trends are reported globally, with studies in the USA and Canada reporting lower uptake of eye services amongst people with lower education and income levels, current smokers, Black ethnic groups and those older than 65 years, with reasons for not seeking eye care including no insurance or cost of examination and lack of perceived eye problem ( 23 , 24 ). Observational studies of real-world data, including the RAINBOW and PERSEUS studies, have consistently shown the association of regular treatment and prompt completion of the loading phase of treatment with better greater acuity outcomes and the same findings have been replicated in the annual reports of the UK AMD audit ( 25 , 26 ). In this audit, 71.7% of eyes overall completed the first 3 injections during the loading phase of treatment within 10 weeks, with little variation across IMD deciles. This is comparable to another observational study in the UK reporting over 75% completion within 10 weeks (n = 7 686) which also reported worse VA with an incomplete loading phase of treatment by LogMAR 0.078 (95% CI 0.039 to 0.12), approximately four ETDRS letters, when compared with eyes with fast loading phase completion( 14 ). Trends towards greater loss to follow-up were also observed in the most deprived deciles in this audit, which has not been reported in other UK studies of AMD. This may be associated with other variables not included in this analysis( 12 , 19 ). Studies in the USA investigating loss to follow up in AMD services have identified other associations including older age, Black or Asian ethnicity, non-English speaking groups and comorbidities such as diabetes or dementia( 27 – 30 ). Factors increasing rates of loss to follow-up in treatment of wet AMD have significant implications on increasing vision loss, and poor baseline VA itself has been linked to increased loss to follow up, suggesting persistent barriers to access throughout the care pathway ( 7 , 31 , 32 ). Distance from home to hospital is also suggested as a reason for loss to follow up in treatment of AMD and other conditions affecting older people, perhaps linked to identifying an escort to the appointment ( 33 , 34 ). Other factors influencing adherence in qualitative studies include logistic barriers, such as booking appointments, and psychological barriers surrounding experience of receiving intravitreal injections ( 35 – 37 ). Strengths of this study include the contribution of data over three years from an estimated 50% of all eligible treatment centres England, comprising one of the largest real-world databases of intravitreal injections for NvAMD, thereby increasing the generalisability of findings. Limitations include the use of only English centres as deprivation is measured differently in Scotland, Wales and Northern Ireland. Furthermore, deprivation data was available for centres using Medisoft or mediSIGHT electronic medical records, but not available from centres using OpenEyes software. Data quality relating to the duration of symptoms and recording of the date of initial referral was poor so that no analysis of delayed presentation to primary care colleagues or delays in starting treatment after diagnosis were possible. Analysis also included the use of two eyes per person introducing patient-level correlation. This audit has found associations between higher socioeconomic deprivation and worse baseline and 12-month VA, despite the patients being younger at the start of treatment and no clear difference in the elements of the care pathway studied. Moreover, this difference in outcome was present in both first and second treated eyes, despite there being no difference in the baseline VA of second treated eyes by decile of deprivation. Further exploration could seek to explain the association between greater deprivation and poorer vision outcomes across both first treated eyes, where differences in baseline VA exist across IMD deciles, and second treated eyes, where there is no difference in baseline VA by decile. This could underpin further investigation of barriers to access to AMD services amongst underserved populations. Declarations Acknowledgements: We would like to acknowledge the support and guidance we have received from the RCOphth NOD AMD Audit Advisory Group. We also acknowledge the support of all the NHS Trusts and ISTCS participating in the audit and thank our medical and non-medical colleagues for the considerable time and effort devoted to conscientious electronic data collection as they go about caring for their patients. The participating centres included in this study are listed in alphabetic order below, separated into the 47 English NHS Trusts, 13 Independent sector treatment sites, Supplementary file 1. Conflict of Interest: Authors declared no conflict of interest Funding : Roche Products Limited have provided funding to support the conduct of this study and the UK AMD Audit. Roche Products Limited has had no further involvement in this project. The UK AMD Audit has also been supported by an unrestricted, hands-off grant provided by Bayer plc. Bayer plc has no involvement whatsoever in the development or implementation of this project. We are grateful for the funding received from these organisations. The UK AMD Audit also receive ongoing support through subscription fees from participating centres. RS is funded by the NIHR (ACF-2023-11-004). Author contribution statement: RS was responsible for conducting initial literature review, contributed to interpreting results and writing the report. 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Drivers of and barriers to adherence to neovascular age-related macular degeneration and diabetic macular edema treatment management plans: a multi-national qualitative study. Patient preference and adherence. 2022:587-604. Polat O, İnan S, Özcan S, Doğan M, Küsbeci T, Yavaş GF, İnan ÜÜ. Factors affecting compliance to intravitreal anti-vascular endothelial growth factor therapy in patients with age-related macular degeneration. Turk Oftalmoloiji Dergisi. 2017;47(4):205-10. Tables Tables are available in the Supplementary Files section. Additional Declarations There is no conflict of interest Supplementary Files SupplementaryFigure1.docx Supplementary Figure 1 Supplementaryfile1.docx Supplementary file 1 SupplementaryTables2and3.docx Supplementary Table 2 and 3 RCOPHTHTable1.xlsx Table 1: Patients’ characteristics, categorised baseline visual acuity (VA), and intravitreal injections for decile of social deprivation. N = 48 583 treated eyes from 60 participating centres. RCOPTHTable2.xlsx Table 2: Categorised visual acuity (VA) at 12 - month, Good VA (N = 39 439), and poor VA (N = 36 792) for decile of the social deprivation from 58 participating centres. Cite Share Download PDF Status: Published Journal Publication published 24 Mar, 2026 Read the published version in Eye → Version 1 posted Editorial decision: revise 03 Nov, 2025 Review # 2 received at journal 01 Nov, 2025 Reviewer # 2 agreed at journal 11 Oct, 2025 Review # 1 received at journal 11 Oct, 2025 Reviewer # 1 agreed at journal 26 Sep, 2025 Reviewers invited by journal 14 Sep, 2025 Editor assigned by journal 27 Aug, 2025 Submission checks completed at journal 20 Aug, 2025 First submitted to journal 20 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-7417262\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Article\",\"associatedPublications\":[],\"authors\":[{\"id\":514747917,\"identity\":\"9ecba19c-e8c2-4303-9254-3b686d7497c8\",\"order_by\":0,\"name\":\"Riddhi Shenoy\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIie3RsWrCQBzH8b8I1+UfXf9Zcj6CIRBa6MP8RcjWqUsGoQHhXPIADUqfoVPnhIO4HJ11kUJf4MDFSVRcisPFscN9puPgC7/jADzvX+qvD5w/gvh71yuciWCyhq5JfV+Co7BSdD3flcilgST4oGjwoPXe5jsYLmoRvjuS8fdLPQ2+KBGYZVSbVyDDIvx0JThgfU4mijCFRjHABkT44xpWYjwPVvSmaLi3zZFBdiVgMOlVBbEgBGoKhvElcQ4zIgPbUqwwS8m0jLGZzJ9cz5dlvwWePUu50L82n3EUrXWzLV3DbmHnR3qe53ndTlaTR46TA1GmAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"Ulverscroft Eye Unit\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Riddhi\",\"middleName\":\"\",\"lastName\":\"Shenoy\",\"suffix\":\"\"},{\"id\":514747918,\"identity\":\"8a08aac1-4c43-4542-8e87-8d343c8b1bb8\",\"order_by\":1,\"name\":\"Mable Monachan\",\"email\":\"\",\"orcid\":\"https://orcid.org/0009-0009-9646-6019\",\"institution\":\"Gloucestershire Hospital NHS Foundation 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07:23:30\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":482732,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eMedian + IQR plots of ETDRS visual acuity (VA) at baseline (N = 48 583 treated eyes from 60 participating centres) and at one-year (N = 39 439 treated eyes from 58 participating centres) by national decile of social deprivation for England. The ‘line’ displays the inter-quartile range (IQR) with the median in the middle. The national decile of social deprivation indicates the most deprived decile (decile 1) up to the least deprived decile (decile 10) of England.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure1blackandwhite.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7417262/v1/a6d41df46ec58e9b770c53c9.png\"},{\"id\":91954415,\"identity\":\"31f5d70b-f9b8-45b5-bdb8-65fa2e9dc3c2\",\"added_by\":\"auto\",\"created_at\":\"2025-09-23 07:07:31\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":641509,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eMedian + IQR plots of decile of the social deprivation by participating centre and ordered by median decile. The ‘line’ displays the inter-quartile range (IQR) with the median in the middle. The national deciles of social deprivation indicate the most deprived (decile 1) up to the least deprived (decile 10) of England. N = 48 583 treated eyes from 60 participating centres.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7417262/v1/c4f911a17acd1116b642283d.png\"},{\"id\":105357958,\"identity\":\"2547ad84-f2cf-4674-bdce-ea5fd6ab6f14\",\"added_by\":\"auto\",\"created_at\":\"2026-03-25 07:13:19\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":2028125,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7417262/v1/1f38395a-63a9-42c7-be66-d1d0a3a9be08.pdf\"},{\"id\":91954404,\"identity\":\"e7c97427-c572-45de-af4a-e19fe0915f8c\",\"added_by\":\"auto\",\"created_at\":\"2025-09-23 07:07:30\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":45555,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSupplementary Figure 1\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"SupplementaryFigure1.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7417262/v1/13f11716924382c0b6376ed9.docx\"},{\"id\":91956478,\"identity\":\"77402f4c-86bb-45e0-b7fd-c8e8f534f1e2\",\"added_by\":\"auto\",\"created_at\":\"2025-09-23 07:15:30\",\"extension\":\"docx\",\"order_by\":2,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":21535,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSupplementary file 1\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Supplementaryfile1.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7417262/v1/42cfee7975b9a7340d08663a.docx\"},{\"id\":91954406,\"identity\":\"5fb675f6-0e2e-4b5f-a633-4d973226bab4\",\"added_by\":\"auto\",\"created_at\":\"2025-09-23 07:07:30\",\"extension\":\"docx\",\"order_by\":3,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":23180,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSupplementary Table 2 and 3\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"SupplementaryTables2and3.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7417262/v1/0d9c32e5b789756476f46304.docx\"},{\"id\":91956481,\"identity\":\"8f9c90aa-fa6d-4a2b-9e08-58ed990e3e0e\",\"added_by\":\"auto\",\"created_at\":\"2025-09-23 07:15:30\",\"extension\":\"xlsx\",\"order_by\":4,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":20159,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eTable 1: Patients’ characteristics, categorised baseline visual acuity (VA), and intravitreal injections for decile of social deprivation. N = 48 583 treated eyes from 60 participating centres.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"RCOPHTHTable1.xlsx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7417262/v1/7c3706625236bf3464398006.xlsx\"},{\"id\":91954412,\"identity\":\"64b3a027-0501-40a7-b587-7fa42b594098\",\"added_by\":\"auto\",\"created_at\":\"2025-09-23 07:07:30\",\"extension\":\"xlsx\",\"order_by\":5,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":19029,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eTable 2: Categorised visual acuity (VA) at 12 - month, Good VA (N = 39 439), and poor VA (N = 36 792) for decile of the social deprivation from 58 participating centres.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"RCOPTHTable2.xlsx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7417262/v1/4dd87d9aad7cbb2abcce909d.xlsx\"}],\"financialInterests\":\"There is no conflict of interest\",\"formattedTitle\":\"The Royal College of Ophthalmologists National Ophthalmology Database Age-related Macular Degeneration Audit: Report 1, Associations with socio-economic deprivation in neovascular age-related macular degeneration\",\"fulltext\":[{\"header\":\"Summary Box\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eWhat was known before\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003eReducing inequity in eye health is a national priority and links between socioeconomic deprivation and advanced eye disease are already described.\\u003c/li\\u003e\\n \\u003cli\\u003eFew studies in the UK have investigated associations between socio-economic deprivation and baseline characteristics, age, key care processes and visual acuity outcomes after treatment for neovascular age-related macular degeneration.\\u0026nbsp;\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eWhat this study adds\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003eSocio-economic deprivation is associated with age and visual acuity at presentation, key care processes and visual acuity outcomes after NHS-funded treatment in England for\\u0026nbsp;neovascular age-related macular degeneration.\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eFurther analysis is required to investigate if socioeconomic deprivation is independently associated with baseline visual acuity and outcomes after treatment.\\u0026nbsp;\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\"},{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eAge related macular degeneration (AMD) is a chronic progressive eye condition and the leading cause of irreversible visual impairment in older people in developed countries, with 200\\u0026nbsp;million people estimated to have AMD worldwide in 2020 (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eNeovascular AMD (NvAMD) is an advanced form of AMD characterised by macular neovascularisation that can cause rapid central vision loss. Early diagnosis and treatment of NvAMD with intravitreal inhibition of vascular endothelial growth factor (VEGF) improves vision outcomes(\\u003cspan additionalcitationids=\\\"CR4\\\" citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e). Notably, along with age, visual acuity (VA) at presentation has been shown to be one of the strongest predictors of long-term vision outcomes (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eInequality in eye health is increasingly being identified across the conditions most responsible for visual impairment, with socioeconomic deprivation in the UK associated with more advanced eye disease and lower uptake of optometry services(\\u003cspan additionalcitationids=\\\"CR9 CR10\\\" citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e). Existing evidence for the association between deprivation and AMD is inconsistent, though real-world data largely indicates disparities by socioeconomic status, with lower baseline vision and greater prevalence of AMD observed amongst those living in areas of greatest deprivation, and subsequent poorer visual acuity outcomes following treatment (\\u003cspan additionalcitationids=\\\"CR13 CR14\\\" citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003e This study reports analysis of data supplied to the Royal College of Ophthalmologists (RCOphth) National Ophthalmology Database (NOD) AMD Audit, investigating associations of deprivation with baseline characteristics, key care processes and VA outcomes in NvAMD.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003eThe RCOphth NOD National AMD Audit is open to centres performing NHS funded treatment of NvAMD within the UK and Channel Islands. The data is collected as part of routine clinical care on electronical medical record systems (EMR) or in-house databases and submitted annually for eyes starting treatment for NvAMD. Further information on the RCOphth NOD AMD Audit can be found on the audit website (\\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ewww.nodaudit.org.uk\\u003c/span\\u003e\\u003c/span\\u003e).\\u003cp\\u003e Eligible for analysis were NHS-funded intravitreal anti-VEGF treatments submitted to RCOphth NOD administered in English centres with at least 25 treated eyes between 01/04/2020 and 31/03/2023 (supplementary file 1 for list of participating centres). Inclusion criteria for eyes required recording of baseline VA and the English Indices of Multiple Deprivation (IMD) 2019 for each patient(\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e). (IMD is a percentile rank estimate of relative deprivation that ranks neighbourhoods in England across seven domains (income, employment, education, health, crime, housing and living environment). Due to different measures of deprivation used in Scotland, Wales and Ireland, only data from England were analysed.) During data extraction, IMD deciles were matched to the patient\\u0026rsquo;s post code, from decile 1 (most deprived) to decile 10 (least deprived), and transferred to the RCOphth NOD without the patient\\u0026rsquo;s postcode. This analysis reports outcomes over the first 12 months of eyes commencing treatment in the 2020\\u0026ndash;2022 NHS years.\\u003c/p\\u003e\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eOutcome measures\\u003c/h2\\u003e\\u003cp\\u003eVA at baseline and after 12 months of treatment (-28 to +\\u0026thinsp;84 days) was recorded in ETDRS letters. A change of five ETDRS letters is equivalent to 0.10 LogMAR unit. A good VA outcome at 12 months was defined as \\u0026ge;\\u0026thinsp;70 ETDRS letters. A poor VA outcome at 12 months was defined as a decrease of \\u0026ge;\\u0026thinsp;10 ETDRS letters from baseline. Eyes with a baseline VA\\u0026thinsp;\\u0026le;\\u0026thinsp;25 ETDRS letters were excluded from poor VA outcome analysis (supplementary Fig.\\u0026nbsp;1).\\u003c/p\\u003e\\u003cp\\u003eLoss to follow-up was defined as eyes for which no clinical information was available at 12 months (+\\u0026thinsp;84 days) following treatment commencement. All eyes with VA data or injection data at one year were considered to have completed follow-up.\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eStatistical analysis\\u003c/h2\\u003e\\u003cp\\u003eAll analyses were performed using STATA 18 (StataCorp. 2023. Stata Statistical Software: Release 18. College Station, TX: StataCorp LLC).\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eBaseline characteristics\\u003c/h2\\u003e\\u003cp\\u003eEligible for analysis were 48 583 eyes of 42 043 patients from 60 English participating centres (including 47 NHS Trusts and 13 independent sector treatment centres). Anti-VEGF injections were administered to 24 001 (49.4%) left eyes and 24 582 (50.6%) right eyes. Of 42 043 patients, 25 240 (60.0%) were female, 15 514 (36.9%) were male, and the gender was not stated for 1 289 (3.1%) patients.\\u003c/p\\u003e\\u003cp\\u003eThe majority of the sample consisted of 33 161 (68.3%) first treated eyes, of which the median age at start of treatment was 81 years (IQR: 75\\u0026ndash;86 years). The number of second treated eyes was 9 864 (20.3%) eyes, with a median age at start of treatment of 83 years (IQR: 77\\u0026ndash;87 years). Immediate sequential bilateral intravitreal treatment (ISBIVT) was given to 5 558 (11.4%) eyes from 2 779 patients, with a median age at start of treatment of 82 years (IQR: 76\\u0026ndash;87 years). The overall prevalence of diabetes mellitus was 12.7% (5 327 patients).\\u003c/p\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003eBaseline visual acuity by IMD decile\\u003c/h3\\u003e\\n\\u003cp\\u003eMedian age ranged from 79 to 82 years from decile 1 to 10 across the sample (Table\\u0026nbsp;1). The median baseline VA was 60 ETDRS letters (IQR: 45\\u0026ndash;70 ETDRS letters), ranging from 56 ETDRS letters in decile 1 to 60 ETDRS letters in decile 10 (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003cp\\u003eFor first treated eyes, the median baseline VA was 55 ETDRS letters (IQR: 40\\u0026ndash;68 ETDRS letters), ranging from 55 ETDRS letters in decile 1 to 59 ETDRS letters in decile 10. For second treated eyes, the median baseline VA was 65 ETDRS letters (IQR: 54\\u0026ndash;71 ETDRS letters), across all deciles.\\u003c/p\\u003e\\u003cp\\u003eTreated eyes from less deprived deciles were more likely to have baseline VA of \\u0026ge;\\u0026thinsp;70 ETDRS letters (29.1%) and less likely to have baseline VA of \\u0026le;\\u0026thinsp;25 ETDRS letters (6.9%) (Table\\u0026nbsp;1).\\u003c/p\\u003e\\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eIntravitreal injection pathway uptake by IMD decile\\u003c/h2\\u003e\\u003cp\\u003eThe proportion of treated eyes from each IMD decile ranged from 6.6\\u0026ndash;13.8% for deciles 1\\u0026ndash;10. All bar 8 centres treated patients from every IMD decile. The median IMD decile from each centre ranged from decile 3 to decile 9 (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003cp\\u003eFrom the sample, 43 754 (90.1%) of eyes treated in traditional NHS centres, representation from IMD deciles ranged from 6.3% (decile 1) to 13.9% (decile 10). Similarly, in the 4 829 (9.9%) of eyes treated in the independent sector, representation ranged from 10.0% (decile 1) to 13.2% (decile 10).\\u003c/p\\u003e\\u003cp\\u003eOver the first year of treatment, 48 583 eyes received a total of 345 062 intravitreal injections, of which the proportion ranged from 6.4\\u0026ndash;13.8% for decile 1\\u0026ndash;10 (Table\\u0026nbsp;1). The initial loading phase of three anti-VEGF injections was completed within 10 weeks of the first injection by 34 827 (71.7%) eyes (Table\\u0026nbsp;1). The median number of anti-VEGF injections per eye was 7 (IQR: 5\\u0026ndash;9). There was little variation across IMD deciles for loading phase completion, and the median number of injections during the first year of treatment.\\u003c/p\\u003e\\u003cp\\u003eOverall, 6 354 (13.1%) eyes were lost to follow up within one year of treatment and the proportion ranged between 13.7\\u0026ndash;11.8% from deciles 1 to 10, being highest in decile 2 (15.5%) (Table\\u0026nbsp;1). While 456 (7.2%) eyes stopped treatment for clinical reasons, there were no reasons reported for 5 008 (78.8%) eyes lost to follow-up.\\u003c/p\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003eVisual acuity at 12 months of treatment by IMD decile\\u003c/h3\\u003e\\n\\u003cp\\u003eAfter one year, VA was recorded for 39 439 (81.2%) eyes from 58 centres. Median VA was 65 ETDRS letters (IQR: 48\\u0026ndash;75 ETDRS letters), ranging from 61 ETDRS letters (decile 1) to 65 ETDRS letters (decile 10) (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). The proportion of eyes in which VA improved by \\u0026gt;\\u0026thinsp;5 ETDRS letters was 39.1%, by \\u0026gt;\\u0026thinsp;10 ETDRS letters was 25% and by \\u0026gt;\\u0026thinsp;15 ETDRS letters was 15%, with similar gains across deciles.\\u003c/p\\u003e\\u003cp\\u003eGood VA (\\u0026ge;\\u0026thinsp;70 ETDRS letters) at 12 months was achieved by 16,414 (41.6%) eyes, ranging from 35.9% (decile 1) to 45.5% (decile 10) (Table\\u0026nbsp;2).\\u003c/p\\u003e\\u003cp\\u003eFrom 39 439 eyes, 36 792 (93.3%) eyes with VA\\u0026thinsp;\\u0026gt;\\u0026thinsp;25 ETDRS letters from the centres with at least 25 eligible eyes were included. Poor VA outcome at 12 months (\\u0026ge;\\u0026thinsp;10 ETDRS letters decrease from baseline VA) was experienced for 5 879 (16.0%) eyes, with 18.3% in decile 1 and 14.5% in decile 10, Table\\u0026nbsp;2.\\u003c/p\\u003e\\u003cp\\u003eThe median VA of first treated eyes ranged from 60 to 65 ETDRS letters between deciles 1 to 10. Median VA at 12 months of second treated eyes ranged from 66 to 70 ETDRS letters between deciles 1 to 10 (Supplementary tables 2 and 3)\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003e This review of UK AMD Audit data collected as part of routine care over a 3-year period has found an association between socio-economic deprivation and both baseline and 12-month VA outcomes of NHS-funded treatment for NvAMD in England, despite few differences in the care pathway. A trend towards greater loss to follow up was also observed in the eyes of patients living in areas of higher deprivation.\\u003c/p\\u003e\\u003cp\\u003eMedian baseline VA was lower in patients from the areas of greatest deprivation and 12-month VA outcomes were also worse, despite these patients being younger at the start of treatment. This is in contrast with published studies that generally report better visual outcomes amongst younger patients and may suggest deprivation is associated with more advanced AMD at presentation(\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e). This may further indicate barriers to access to diagnosis of AMD in areas of deprivation that are reflected in findings from previous UK studies(\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e). One single centre retrospective study in the UK (n\\u0026thinsp;=\\u0026thinsp;756) reported that people living in the most deprived areas were significantly more likely, when compared to those from the least deprived areas, to present with severe reduction in acuity, after adjusting for age, gender and distance from treatment centre (OR\\u0026thinsp;=\\u0026thinsp;4.07; 95% Cl\\u0026thinsp;=\\u0026thinsp;1.50\\u0026ndash;11.0; P\\u0026thinsp;=\\u0026thinsp;.006,)(\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e). Similar associations were reported in another single centre retrospective study in Birmingham (n\\u0026thinsp;=\\u0026thinsp;120), but were not found in a similar study in Glasgow (n\\u0026thinsp;=\\u0026thinsp;240). However, significant limitations of these retrospective studies include variable measures of deprivation used, variable inclusion of relevant confounders and small sample sizes (\\u003cspan additionalcitationids=\\\"CR20\\\" citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eComparing first and second treated eyes, the trend to poorer baseline VA with greater deprivation was only seen in first treated eyes, suggesting that patients developing NvAMD in their second eye, likely identified through monitoring in secondary care, may not experience the same initial barriers to access. However, the trend to poorer 12-month VA was seen in both first and second treated eyes, suggesting that socio-economic deprivation may have an independent association with acuity outcomes, rather than simply being a surrogate marker of baseline VA. Across all treated eyes, 12-month VA outcomes in this audit remained worse in the eyes of patients from areas of highest deprivation.\\u003c/p\\u003e\\u003cp\\u003eBarriers to access to primary care, where patients with AMD may first present, may contribute to the association seen with deprivation and worse baseline VA. Analysis of NHS digital data has shown substantial variation in the provision of optometry services in England with much lower rates in more deprived areas versus more affluent areas(\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e). Inequalities in uptake of eye examinations have also been shown, with analysis of General Ophthalmic Services (GOS) claims for eye examinations in the UK showing people aged over 60 years living in the least deprived areas being 15\\u0026ndash;71% more likely to access an NHS funded eye examination compared to those in the same age group living in the most deprived areas(\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e). Similar trends are reported globally, with studies in the USA and Canada reporting lower uptake of eye services amongst people with lower education and income levels, current smokers, Black ethnic groups and those older than 65 years, with reasons for not seeking eye care including no insurance or cost of examination and lack of perceived eye problem (\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eObservational studies of real-world data, including the RAINBOW and PERSEUS studies, have consistently shown the association of regular treatment and prompt completion of the loading phase of treatment with better greater acuity outcomes and the same findings have been replicated in the annual reports of the UK AMD audit (\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e). In this audit, 71.7% of eyes overall completed the first 3 injections during the loading phase of treatment within 10 weeks, with little variation across IMD deciles. This is comparable to another observational study in the UK reporting over 75% completion within 10 weeks (n\\u0026thinsp;=\\u0026thinsp;7 686) which also reported worse VA with an incomplete loading phase of treatment by LogMAR 0.078 (95% CI 0.039 to 0.12), approximately four ETDRS letters, when compared with eyes with fast loading phase completion(\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eTrends towards greater loss to follow-up were also observed in the most deprived deciles in this audit, which has not been reported in other UK studies of AMD. This may be associated with other variables not included in this analysis(\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e). Studies in the USA investigating loss to follow up in AMD services have identified other associations including older age, Black or Asian ethnicity, non-English speaking groups and comorbidities such as diabetes or dementia(\\u003cspan additionalcitationids=\\\"CR28 CR29\\\" citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e). Factors increasing rates of loss to follow-up in treatment of wet AMD have significant implications on increasing vision loss, and poor baseline VA itself has been linked to increased loss to follow up, suggesting persistent barriers to access throughout the care pathway (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e). Distance from home to hospital is also suggested as a reason for loss to follow up in treatment of AMD and other conditions affecting older people, perhaps linked to identifying an escort to the appointment (\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e). Other factors influencing adherence in qualitative studies include logistic barriers, such as booking appointments, and psychological barriers surrounding experience of receiving intravitreal injections (\\u003cspan additionalcitationids=\\\"CR36\\\" citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eStrengths of this study include the contribution of data over three years from an estimated 50% of all eligible treatment centres England, comprising one of the largest real-world databases of intravitreal injections for NvAMD, thereby increasing the generalisability of findings. Limitations include the use of only English centres as deprivation is measured differently in Scotland, Wales and Northern Ireland. Furthermore, deprivation data was available for centres using Medisoft or mediSIGHT electronic medical records, but not available from centres using OpenEyes software. Data quality relating to the duration of symptoms and recording of the date of initial referral was poor so that no analysis of delayed presentation to primary care colleagues or delays in starting treatment after diagnosis were possible. Analysis also included the use of two eyes per person introducing patient-level correlation.\\u003c/p\\u003e\\u003cp\\u003eThis audit has found associations between higher socioeconomic deprivation and worse baseline and 12-month VA, despite the patients being younger at the start of treatment and no clear difference in the elements of the care pathway studied. Moreover, this difference in outcome was present in both first and second treated eyes, despite there being no difference in the baseline VA of second treated eyes by decile of deprivation. Further exploration could seek to explain the association between greater deprivation and poorer vision outcomes across both first treated eyes, where differences in baseline VA exist across IMD deciles, and second treated eyes, where there is no difference in baseline VA by decile. This could underpin further investigation of barriers to access to AMD services amongst underserved populations.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements:\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe would like to acknowledge the support and guidance we have received from the RCOphth NOD AMD Audit Advisory Group. We also acknowledge the support of all the NHS Trusts and ISTCS participating in the audit and thank our medical and non-medical colleagues for the considerable time and effort devoted to conscientious electronic data collection as they go about caring for their patients.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe participating centres included in this study are listed in alphabetic order below, separated into the 47 English NHS Trusts, 13 Independent sector treatment sites, Supplementary file 1.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConflict of Interest:\\u003c/strong\\u003e Authors declared no conflict of interest\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eRoche Products Limited have provided funding to support the conduct of this study and the UK AMD Audit. Roche Products Limited has had no further involvement in this project. The UK AMD Audit has also been supported by an unrestricted, hands-off grant provided by Bayer plc. Bayer plc has no involvement whatsoever in the development or implementation of this project. We are grateful for the funding received from these organisations. The UK AMD Audit also receive ongoing support through subscription fees from participating centres. RS is funded by the NIHR (ACF-2023-11-004).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor contribution statement:\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eRS was responsible for conducting initial literature review, contributed to interpreting results and writing the report. MTM was responsible for designing the methodology, analysing the data and writing the report. MGG was responsible for designing the methodology, analysing the data and writing the report. MM was responsible for designing the methodology, interpreting the results and writing the report.\\u003c/p\\u003e\\n\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eFurtado JM, Jonas JB, Tapply I, Fernandes AG, Cicinelli MV, Arrigo A, et al. Global estimates on the number of people blind or visually impaired by age-related macular degeneration: a meta-analysis from 2000 to 2020. Eye. 2024;38(11):2070-82.\\u003c/li\\u003e\\n\\u003cli\\u003eWong WL, Su X, Li X, Cheung CMG, Klein R, Cheng C-Y, Wong TY. Global prevalence of age-related macular degeneration and disease burden projection for 2020 and 2040: a systematic review and meta-analysis. The Lancet Global Health. 2014;2(2):e106-e16.\\u003c/li\\u003e\\n\\u003cli\\u003eLim JH, Wickremasinghe SS, Xie J, Chauhan DS, Baird PN, Robman LD, et al. Delay to Treatment and Visual Outcomes in Patients Treated With Anti-Vascular Endothelial Growth Factor for Age-Related Macular Degeneration. American Journal of Ophthalmology. 2012;153(4):678-86.e2.\\u003c/li\\u003e\\n\\u003cli\\u003eWeber M, Dominguez M, Coscas F, Faure C, Baillif S, Kodjikian L, Cohen S-Y. Impact of intravitreal aflibercept dosing regimens in treatment-na\\u0026iuml;ve patients with neovascular age-related macular degeneration: 2-year results of RAINBOW. BMC Ophthalmology. 2020;20(1):206.\\u003c/li\\u003e\\n\\u003cli\\u003eSchmidt-Erfurth U, Chong V, Loewenstein A, Larsen M, Souied E, Schlingemann R, et al. Guidelines for the management of neovascular age-related macular degeneration by the European Society of Retina Specialists (EURETINA). British Journal of Ophthalmology. 2014;98(9):1144-67.\\u003c/li\\u003e\\n\\u003cli\\u003eHo AC, Albini TA, Brown DM, Boyer DS, Regillo CD, Heier JS. The Potential Importance of Detection of Neovascular Age-Related Macular Degeneration When Visual Acuity Is Relatively Good. JAMA Ophthalmology. 2017;135(3):268-73.\\u003c/li\\u003e\\n\\u003cli\\u003eMollan SP, Fu DJ, Chuo C-Y, Gannon JG, Lee WH, Hopkins JJ, et al. Predicting the immediate impact of national lockdown on neovascular age-related macular degeneration and associated visual morbidity: an INSIGHT Health Data Research Hub for Eye Health report. The British journal of ophthalmology. 2023;107(2):267-74.\\u003c/li\\u003e\\n\\u003cli\\u003eShickle D, Farragher TM, Davey CJ, Slade SV, Syrett J. Geographical inequalities in uptake of NHS funded eye examinations: Poisson modelling of small-area data for Essex, UK. Journal of Public Health. 2017;40(2):e171-e9.\\u003c/li\\u003e\\n\\u003cli\\u003eEngland L, O\\u0026apos;Connor A. Do Socioeconomic Inequalities Exist Within Ophthalmology and Orthoptics in the UK?: A Scoping Review. The British and Irish orthoptic journal. 2024;20(1):31-47.\\u003c/li\\u003e\\n\\u003cli\\u003eWong TL, Ang JL, Deol S, Buckmaster F, McTrusty AD, Tatham AJ. 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BMJ Open Ophthalmology. 2022;7(1):e001038.\\u003c/li\\u003e\\n\\u003cli\\u003eRelton SD, Chi GC, Lotery AJ, West RM, Real world AMDtoEMRUG, McKibbin M. Associations with baseline visual acuity in 12,414 eyes starting treatment for neovascular AMD. Eye (London, England). 2023;37(8):1652-8.\\u003c/li\\u003e\\n\\u003cli\\u003eMinistry of Housing CLG. English indices of deprivation 2019 (IoD2019). 2019 26 September 2019.\\u003c/li\\u003e\\n\\u003cli\\u003eRosenfeld PJ, Shapiro H, Tuomi L, Webster M, Elledge J, Blodi B. Characteristics of Patients Losing Vision after 2 Years of Monthly Dosing in the Phase III Ranibizumab Clinical Trials. Ophthalmology. 2011;118(3):523-30.\\u003c/li\\u003e\\n\\u003cli\\u003eYing G-s, Huang J, Maguire MG, Jaffe GJ, Grunwald JE, Toth C, et al. Baseline Predictors for One-Year Visual Outcomes with Ranibizumab or Bevacizumab for Neovascular Age-related Macular Degeneration. Ophthalmology. 2013;120(1):122-9.\\u003c/li\\u003e\\n\\u003cli\\u003eSharma HE, Mathewson PA, Lane M, Shah P, Glover N, Palmer H, et al. The role of social deprivation in severe neovascular age-related macular degeneration. British Journal of Ophthalmology. 2014;98(12):1625-8.\\u003c/li\\u003e\\n\\u003cli\\u003eMore P, Almuhtaseb H, Smith D, Fraser S, Lotery AJ. Socio-economic status and outcomes for patients with age-related macular degeneration. Eye (London, England). 2019;33(8):1224-31.\\u003c/li\\u003e\\n\\u003cli\\u003eAcharya N, Lois N, Townend J, Zaher S, Gallagher M, Gavin M. Socio-economic deprivation and visual acuity at presentation in exudative age-related macular degeneration. British Journal of Ophthalmology. 2009;93(5):627-9.\\u003c/li\\u003e\\n\\u003cli\\u003eShickle D, Farragher TM. Geographical inequalities in uptake of NHS-funded eye examinations: small area analysis of Leeds, UK. Journal of public health (Oxford, England). 2015;37(2):337-45.\\u003c/li\\u003e\\n\\u003cli\\u003eSherman E, Niziol LM, Hicks PM, Johnson-Griggs M, Elam AR, Woodward MA, et al. A Screening Strategy to Mitigate Vision Impairment by Engaging Adults Who Underuse Eye Care Services. JAMA Ophthalmology. 2024;142(10):909-16.\\u003c/li\\u003e\\n\\u003cli\\u003eAljied R, Aubin MJ, Buhrmann R, Sabeti S, Freeman EE. Eye care utilization and its determinants in Canada. Canadian Journal of Ophthalmology. 2018;53(3):298-304.\\u003c/li\\u003e\\n\\u003cli\\u003eMichel W, Laurent K, Florence C, C\\u0026eacute;line F, Isabelle A, Ingrid D, Salomon YC. Impact of intravitreal aflibercept dosing regimens in treatment-na\\u0026Atilde;\\u0026macr;ve patients with neovascular age-related macular degeneration in routine clinical practice in France: results from the RAINBOW study. BMJ Open Ophthalmology. 2020;5(1):e000377.\\u003c/li\\u003e\\n\\u003cli\\u003eFramme C, Eter N, Hamacher T, Hasanbasic Z, Jochmann C, Johnson KT, et al. Aflibercept for Patients with Neovascular Age-Related Macular Degeneration in Routine Clinical Practice in Germany: Twelve-Month Outcomes of PERSEUS. Ophthalmology Retina. 2018;2(6):539-49.\\u003c/li\\u003e\\n\\u003cli\\u003eHamedani AG, Chang AY, Chen Y, VanderBeek BL. Disparities in glaucoma and macular degeneration healthcare utilization among persons living with dementia in the United States. Graefe\\u0026apos;s Archive for Clinical and Experimental Ophthalmology. 2024;262(12):3947-55.\\u003c/li\\u003e\\n\\u003cli\\u003eKhurana RN, Li C, Lum F. Loss to Follow-up in Patients with Neovascular Age-Related Macular Degeneration Treated with Anti\\u0026ndash;VEGF Therapy in the United States in the IRIS\\u0026reg; Registry. Ophthalmology. 2023;130(7):672-83.\\u003c/li\\u003e\\n\\u003cli\\u003eNguyen AH, Davoudi S, Dong K, Bains A, Ness S, Subramanian ML, et al. Socioeconomic Disparities in Patients Receiving Intravitreal Injections for Age-Related Macular Degeneration Amid the COVID-19 Pandemic. Journal of VitreoRetinal Diseases. 2023;7(5):376-81.\\u003c/li\\u003e\\n\\u003cli\\u003eObeid A, Gao X, Ali FS, Aderman CM, Shahlaee A, Adam MK, et al. Loss to Follow-up Among Patients With Neovascular Age-Related Macular Degeneration Who Received Intravitreal Anti-Vascular Endothelial Growth Factor Injections. JAMA Ophthalmology. 2018;136(11):1251-9.\\u003c/li\\u003e\\n\\u003cli\\u003eKusenda P, Caprnda M, Gabrielova Z, Kukova N, Pavlovic S, Stefanickova J. Understanding Loss to Follow-Up in AMD Patients Receiving VEGF Inhibitor Therapy: Associated Factors and Underlying Reasons. Diagnostics. 2024;14(4).\\u003c/li\\u003e\\n\\u003cli\\u003ePolat O, İnan S, \\u0026Ouml;zcan S, Doğan M, K\\u0026uuml;sbeci T, Yavaş GF, İnan \\u0026Uuml;\\u0026Uuml;. Factors Affecting Compliance to Intravitreal Anti-Vascular Endothelial Growth Factor Therapy in Patients with Age-Related Macular Degeneration. Turkish Journal of Ophthalmology / Turk Oftalmoloji Dergisi. 2017;47(4):205-10.\\u003c/li\\u003e\\n\\u003cli\\u003eBoulanger-Scemama E, Querques G, About F, Puche N, Srour M, Mane V, et al. Ranibizumab for exudative age-related macular degeneration: A five year study of adherence to follow-up in a real-life setting. Journal Francais d\\u0026apos;Ophtalmologie. 2015;38(7):620-7.\\u003c/li\\u003e\\n\\u003cli\\u003eMeer EA, Targ S, Zhang N, Hoggatt KJ, Mehta KM, Brodie F. Age-Related Macular Degeneration Injection Frequency: Effects of Distance Traveled and Travel Support. Retina. 2024;44(2):230-6.\\u003c/li\\u003e\\n\\u003cli\\u003eM\\u0026uuml;ller S, Junker S, Wilke T, Lommatzsch A, Schuster AK, Kaymak H, et al. Questionnaire for the assessment of adherence barriers of intravitreal therapy: the ABQ-IVT. International Journal of Retina and Vitreous. 2021;7(1):43.\\u003c/li\\u003e\\n\\u003cli\\u003eGiocanti-Aur\\u0026eacute;gan A, Garc\\u0026iacute;a-Layana A, Peto T, Gentile B, Chi GC, Mirt M, et al. Drivers of and barriers to adherence to neovascular age-related macular degeneration and diabetic macular edema treatment management plans: a multi-national qualitative study. Patient preference and adherence. 2022:587-604.\\u003c/li\\u003e\\n\\u003cli\\u003ePolat O, İnan S, \\u0026Ouml;zcan S, Doğan M, K\\u0026uuml;sbeci T, Yavaş GF, İnan \\u0026Uuml;\\u0026Uuml;. Factors affecting compliance to intravitreal anti-vascular endothelial growth factor therapy in patients with age-related macular degeneration. Turk Oftalmoloiji Dergisi. 2017;47(4):205-10.\\u003cstrong\\u003e\\u003cstrong\\u003e\\u003c/strong\\u003e\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp\\u003eTables are available in the Supplementary Files section.\\u003c/p\\u003e\\n\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"eye\",\"isNatureJournal\":false,\"hasQc\":false,\"allowDirectSubmit\":false,\"externalIdentity\":\"eye\",\"sideBox\":\"Learn more about [Eye](http://www.nature.com/eye/)\",\"snPcode\":\"41433\",\"submissionUrl\":\"https://mts-eye.nature.com/cgi-bin/main.plex\",\"title\":\"Eye\",\"twitterHandle\":\"@eye_journal\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"ejp\",\"reportingPortfolio\":\"Nature AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7417262/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7417262/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eEarly diagnosis and treatment of neovascular age-related macular degeneration (NvAMD) improve vision outcomes. This analysis investigates associations of English indices of multiple deprivation 2019 (IMD2019) with baseline characteristics, key care processes and visual acuity (VA) outcomes for NvAMD in the National Ophthalmology Database (NOD).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods\\u003c/strong\\u003e:\\u003c/p\\u003e\\n\\u003cp\\u003eEligible eyes started treatment for NvAMD in England between 01/04/2020 and 31/03/2023. Participating centres with ≥25 eyes with baseline VA and IMD2019 data were included.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eEligible for analysis were 48 583 eyes from 60 English centres. Median age at start of treatment ranged from 79-82 years between deciles 1 (most deprived) to 10 (least deprived). Median baseline VA ranged from 56 to 60 ETDRS letters for deciles 1 to 10.\\u003c/p\\u003e\\n\\u003cp\\u003eAfter one year of treatment (-28 to +84 days), the median number of injections administered ranged from 7-8 for deciles 1 to 10. Loss to follow-up was observed in 13.7% in decile 1, and 11.8% in decile 10. Median VA ranged from 61 to 65 ETDRS letters for deciles 1 to 10. A good VA outcome (≥70 ETDRS letters) was achieved by 35.9% of eyes in decile 1 and 45.5% in decile 10. A poor VA outcome, (decrease of ≥10 ETDRS letters from baseline) was experienced by 18.4% of eyes in decile 1 and 14.5% in decile 10.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003ePatients starting NHS-funded treatment in England for NvAMD and living in areas of higher socio-economic deprivation were typically younger, had lower baseline acuity and achieved worse VA outcomes than those from lower deprivation areas, despite receiving similar treatment.\\u003c/p\\u003e\",\"manuscriptTitle\":\"The Royal College of Ophthalmologists National Ophthalmology Database Age-related Macular Degeneration Audit: Report 1, Associations with socio-economic deprivation in neovascular age-related macular degeneration\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-09-23 07:07:26\",\"doi\":\"10.21203/rs.3.rs-7417262/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"revise\",\"date\":\"2025-11-03T09:37:16+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"This content is not available.\",\"date\":\"2025-11-01T11:15:52+00:00\",\"index\":2,\"fulltext\":\"This content is not available.\"},{\"type\":\"reviewerAgreed\",\"content\":\"This content is not available.\",\"date\":\"2025-10-11T07:02:15+00:00\",\"index\":2,\"fulltext\":\"This content is not available.\"},{\"type\":\"editorInvitedReview\",\"content\":\"This content is not available.\",\"date\":\"2025-10-11T05:37:49+00:00\",\"index\":1,\"fulltext\":\"This content is not available.\"},{\"type\":\"reviewerAgreed\",\"content\":\"This content is not available.\",\"date\":\"2025-09-26T11:09:24+00:00\",\"index\":1,\"fulltext\":\"This content is not available.\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-09-14T06:51:37+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-08-27T12:09:16+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-08-20T14:11:08+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Eye\",\"date\":\"2025-08-20T12:01:14+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"eye\",\"isNatureJournal\":false,\"hasQc\":false,\"allowDirectSubmit\":false,\"externalIdentity\":\"eye\",\"sideBox\":\"Learn more about [Eye](http://www.nature.com/eye/)\",\"snPcode\":\"41433\",\"submissionUrl\":\"https://mts-eye.nature.com/cgi-bin/main.plex\",\"title\":\"Eye\",\"twitterHandle\":\"@eye_journal\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"ejp\",\"reportingPortfolio\":\"Nature AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"bdb340c1-96fd-4ec6-9ad6-d3aa45104599\",\"owner\":[],\"postedDate\":\"September 23rd, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[{\"id\":54680267,\"name\":\"Health sciences/Health care/Public health/Epidemiology\"},{\"id\":54680268,\"name\":\"Scientific community and society/Scientific community\"}],\"tags\":[],\"updatedAt\":\"2026-03-25T07:12:31+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-7417262\",\"link\":\"https://doi.org/10.1038/s41433-026-04382-8\",\"journal\":{\"identity\":\"eye\",\"isVorOnly\":false,\"title\":\"Eye\"},\"publishedOn\":\"2026-03-24 04:00:00\",\"publishedOnDateReadable\":\"March 24th, 2026\"},\"versionCreatedAt\":\"2025-09-23 07:07:26\",\"video\":\"\",\"vorDoi\":\"10.1038/s41433-026-04382-8\",\"vorDoiUrl\":\"https://doi.org/10.1038/s41433-026-04382-8\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7417262\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7417262\",\"identity\":\"rs-7417262\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}