Pixium Vision AMD study - US

AMD Study introduction

The scope of the following questionnaire is to collect the opinions and perspectives directly from patients, and public such as carers, on the most important daily expectations and needs of people affected by "advanced, dry" age related macular degeneration (AMD). This questionnaire is particularly focused on the end-stage, advanced form of dry AMD called "geographic atrophy" where patients lose complete vision in the central visual field. Currently, there is no sufficient medical treatment for dry AMD. This questionnaire is completely anonymized, no personal data will be collected. The anonymized data resulting from the following questionnaire will be collected by Pixium Vision to assist with regulatory applications for a new retinal implant device as part of a human research trial in the UK. Pixium Vision is a company based in France developing a "bionic" electronic medical device to restore partial central vision in patients affected by "advanced, dry" AMD.

If you are a person affected by advanced, dry AMD, you should be helped by somebody with normal eyesight to read and fill the questionnaire.

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* 1. You are

Physician

Orthoptist

Patient with AMD

Relative of patient with AMD

Other

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* 2. If you are a patient with AMD, are you registered with visual impairment?

Partial sight registration

Severe sight/blind registration

Not applicable

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* 3. Before reading the questionnaire, could you please indicate the three most important tasks that you can no longer perform due to your vision

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* 4. Below there is a list of 12 activities, could you identify the three most important tasks that you can no longer perform due to your vision ?

Find your way around a place (find the elevator, toilets, directional signs)

Make your everyday payments (recognize the currency, use your bank card)

Recognize the right ingredients and differentiate them

Use appliance (like oven, washing machine, weight scale)

Recognize and read your mail

Recognize and differentiate people

Complete administrative documents

Enjoy your hobbies (cross words, card games, board games, sew, tinker)

Read a train table at the station or read street names and numbers to reach an address

Use your phone

Find objects at home or on a shelf

Ring the right person and make a digital code at the entrance of a building

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* 5. For these daily living activities, how do you do them today? (For each activity, there are 5 possible answers listed across the top of the form)

	I don't do it anymore, not even helped	Somebody helps me	I have learned to use my other senses to do it	I can still do it with my peripheral vision	I use a device
Make your everyday payments (recognize the currency, use your bank card)	Make your everyday payments (recognize the currency, use your bank card) I don't do it anymore, not even helped	Make your everyday payments (recognize the currency, use your bank card) Somebody helps me	Make your everyday payments (recognize the currency, use your bank card) I have learned to use my other senses to do it	Make your everyday payments (recognize the currency, use your bank card) I can still do it with my peripheral vision	Make your everyday payments (recognize the currency, use your bank card) I use a device
Recognize and differentiate people	Recognize and differentiate people I don't do it anymore, not even helped	Recognize and differentiate people Somebody helps me	Recognize and differentiate people I have learned to use my other senses to do it	Recognize and differentiate people I can still do it with my peripheral vision	Recognize and differentiate people I use a device
Cooking : Use appliance like oven, find ingredients on a shelve and differentiate them	Cooking : Use appliance like oven, find ingredients on a shelve and differentiate them I don't do it anymore, not even helped	Cooking : Use appliance like oven, find ingredients on a shelve and differentiate them Somebody helps me	Cooking : Use appliance like oven, find ingredients on a shelve and differentiate them I have learned to use my other senses to do it	Cooking : Use appliance like oven, find ingredients on a shelve and differentiate them I can still do it with my peripheral vision	Cooking : Use appliance like oven, find ingredients on a shelve and differentiate them I use a device
Moving outside: Read a train table at the station, street names, find an elevator, the toilets	Moving outside: Read a train table at the station, street names, find an elevator, the toilets I don't do it anymore, not even helped	Moving outside: Read a train table at the station, street names, find an elevator, the toilets Somebody helps me	Moving outside: Read a train table at the station, street names, find an elevator, the toilets I have learned to use my other senses to do it	Moving outside: Read a train table at the station, street names, find an elevator, the toilets I can still do it with my peripheral vision	Moving outside: Read a train table at the station, street names, find an elevator, the toilets I use a device
Complete administrative documents and Read your mail	Complete administrative documents and Read your mail I don't do it anymore, not even helped	Complete administrative documents and Read your mail Somebody helps me	Complete administrative documents and Read your mail I have learned to use my other senses to do it	Complete administrative documents and Read your mail I can still do it with my peripheral vision	Complete administrative documents and Read your mail I use a device
Use your phone	Use your phone I don't do it anymore, not even helped	Use your phone Somebody helps me	Use your phone I have learned to use my other senses to do it	Use your phone I can still do it with my peripheral vision	Use your phone I use a device
Enjoy your hobbies: arrow words, card games, board games, sew, tinker	Enjoy your hobbies: arrow words, card games, board games, sew, tinker I don't do it anymore, not even helped	Enjoy your hobbies: arrow words, card games, board games, sew, tinker Somebody helps me	Enjoy your hobbies: arrow words, card games, board games, sew, tinker I have learned to use my other senses to do it	Enjoy your hobbies: arrow words, card games, board games, sew, tinker I can still do it with my peripheral vision	Enjoy your hobbies: arrow words, card games, board games, sew, tinker I use a device

If you tick "I use a device", please indicate the name of the device