Quality of life in age-related macular degeneration: a review of available vision-specific psychometric tools

Piloting Rasch model scoring of the National Eye Institute Visual Function Questionnaire in uveitis

INTRODUCTION

The National Eye Institute Visual Function Questionnaire (NEI VFQ) is a common patient-reported outcome measure (PROM) in uveitis trials. Its psychometric properties using state-of-the-art scoring based on Rasch models, a latent trait model that improves accuracy of PROMs assessment, has not yet been investigated.

METHODS

The study participants were recruited online from uveitis patient organizations, where individuals self-reported their uveitis diagnosis and visual acuity level. These participants then completed the NEI VFQ-25. The visual function (VF) and socioemotional (SE) subscales were psychometrically analysed in terms of item fit, targeting, internal consistency, dimensionality, and differential item functioning (DIF), using Rasch models. Criterion validity was examined based on associations between NEI VFQ person measures and recent visual acuity (VA) levels.

RESULTS

Ninety-nine participants recruited online from uveitis patient organizations (68 women, 31 men; mean age 50 ± 15 years; 46.5% self-reported receiving systematic therapy for uveitis, 0.6% NEI VFQ-25 missing data) were included. The mean difficulty of items was lower than the average person ability. None of the items demonstrated misfit to an extent that would induce noise into the measurement. The consistency metrics person reliability and person separation index of the subscales were 0.85 and 2.34 (NEI VFQ-VF), 0.86 and 2.52 (NEI VFQ-SE), respectively. There was no evidence of multidimensionality and none of the items showed DIF by gender. The differences between item and person measures were 1.44 (NEI VFQ-VF) and 1.03 (NEI VFQ-SE). NEI VFQ-25 person measures were significantly lower in participants with visual impairment (all p values ≤ 0.007).

CONCLUSION

Rasch model-based scoring of the re-engineered NEI VFQ-25 demonstrates acceptable internal consistency, item fit and construct validity for assessing two key domains of quality of life in individuals self-reporting uveitis. The PROM was targeted at a higher level of difficulty than present in our heterogeneous sample.

The 6-Item Vision-Related Quality of Life and Limitations Questionnaire: Evaluation of Psychometric Properties

Purpose

We developed the Vision-related Quality of life and Limitations Questionnaire (VQL-6), a screening instrument to signal a need for additional care resulting from reduced vision-related quality of life in patients with chronic ophthalmic diseases. The aim of the present study was to evaluate psychometric properties.

Methods

A Dutch population-based sample of 2032 participants (mean age, 55 ± 19 years) completed the VQL-6 and other questionnaires on vision-related quality of life, executive functioning, attention, mental health, and symptom validity. In addition, we recruited a sample of 208 ophthalmic patients (mean age, 72 ± 12 years) and 98 age and gender similar controls (mean age, 69 ± 11 years) who completed the VQL-6 and the National Eye Institute Visual Function Questionnaire-25. We studied the factor structure, internal consistency, convergent and divergent validity, and known-groups validity.

Results

For the factor analyses, the population-based sample was split randomly in two subsamples. Exploratory factor analysis on the first subsample suggested a two-factor model (visual limitations and general health and quality of life), which was supported by confirmatory factor analyses on the second subsample, and on the patients. The VQL-6 demonstrated good internal consistency within each factor (0.78-0.89), sufficient convergent (r2= 55%) and divergent validity (r2 = 11%-24%), and good known-groups validity (Cohen's r = 0.57; P < 0.001).

Conclusions

The VQL-6 has a robust two-factor structure and seems to be a valid tool to assess vision-related quality of life. Additional validation is needed in patients with chronic ophthalmic diseases.

Translational Relevance

Future research is needed to determine if the VQL-6 can be used to identify patients with chronic ophthalmic diseases who are in need of additional care.

Neovascular age-related macular degeneration: disease pathogenesis and current state of molecular biomarkers predicting treatment response-a scoping review

Age-related macular degeneration is a major cause of blindness, and the development of anti-vascular endothelial growth factor (VEGF) intravitreal treatments has revolutionised the management of the disease. At the same time, new challenges and unmet needs arose due to the limitations of the current therapeutic options. Neovascularisation development during the course of the disease has a complex pathogenetic mechanism, and several biomarkers and their association with treatment outcomes have been investigated. We reviewed the relevant literature about neovascularisation development and biomarkers related to response to treatment. Improving our knowledge on the field can improve patient outcomes and offer personalised care.

Relationships between Patient-Reported Outcome Measures and Clinical Measures in Naïve Neovascular Age-Related Macular Degeneration Patients Treated with Intravitreal Ranibizumab

Our objective was to evaluate changes in patient-reported outcome measures using the NEI-VFQ 25 questionnaire during a treat and extend regimen in naive neovascular Age-Related Macular Degeneration patients, and its correlation with anatomical and functional data. We conducted a prospective observational study. Patients underwent a treat and extend regimen with intravitreal ranibizumab for neovascular Age-Related Macular Degeneration. Initial response was evaluated at 4th month, and subsequently in every follow-up visit. If a clinical response was achieved, the injection interval was extended in two-week increments, up to a maximum of 12 weeks. Quality of life was assessed using the NEI-VFQ 25 questionnaire at baseline, 4th months, and 12th months. Patients were categorized as good or poor responders based on Best corrected visual acuity, central foveal thickness, intraretinal fluid, or subretinal fluid. Treatment with ranibizumab led to a significant improvement in quality of life, with a mean increase in NEI-VFQ 25 score of 4.27 points in the 12th month. No significant differences in improvement were observed between good and poor responders. Quality of life scores in neovascular Age-Related Macular Degeneration patients improved with intravitreal treatment regardless of the clinical response. The early response following the loading phase could indicate better quality of life after one year of treatment, with Best corrected visual acuity being the clinical parameter with the greatest influence on quality of life.

Monocular and Binocular Visual Function Assessments and Activities of Daily Living Performance in Age-Related Macular Degeneration

PURPOSE

To evaluate the relationship between specific monocular and binocular visual function (VF) assessments with binocularly performed activities of daily living task tests (ADLTTs) in patients with age-related macular degeneration (AMD) and healthy controls.

DESIGN

Prospective case-control cohort study.

SUBJECTS

Thirty-six AMD patients and 36 controls.

METHOD

Visual field assessments included monocular and binocular best-corrected visual acuity (BCVA), contrast sensitivity (CS), and monocular microperimetry testing for mean macula sensitivity, mean retina sensitivity (MRS), fixation area, and fixation distance from fovea (FDF). Age-related macular degeneration lesion area and sensitivity were measured on OCT and microperimetry, respectively. Participants performed 4 validated ADLTTs with binocular BCVA: (1) reading; (2) item-search; (3) money-counting; and (4) multi-step drink-making tasks.

MAIN OUTCOME MEASURES

Spearman correlations and multivariate regression analysis, adjusted for age, sex, and potential correlation between the 2 eyes, were used to assess the relationship between monocular and binocular VF assessments, and ADLTT performance in both groups.

RESULTS

Age-related macular degeneration patients had poorer VF (BCVA, CS, mean macula sensitivity, and MRS) compared with healthy controls. Monocular BCVA in both better- and worse-vision eyes was moderately correlated with the binocular reading speed and money-counting tasks in participants with AMD. In AMD, monocular worse eye CS, MRS, AMD lesion area on OCT, and lesion sensitivity on microperimetry showed moderate correlations to various ADLTTs, such as reading, money-counting, and drink-making. Similar findings were found in our AMD cohort on multivariate regression analysis. Fewer significant correlations were observed for the better-vision eye, whereas no correlations were observed for healthy controls between VF parameters and ADLTTs. In contrast, significant associations were observed between binocular BCVA and CS with binocular ADLTTs (reading and item-search tasks) but not in AMD patients.

CONCLUSION

Although monocular BCVA remains the most common measure of VF, CS and microperimetry testing also show significant correlations with ADLTTs performance in AMD patients, and should be considered as complimentary VF-outcome measures in both clinical and research settings. Unlike healthy subjects, AMD patients do not rely on binocular VF for ADLTT function, with the worse-vision eye impacting binocular ADLTT function more than the better-vision eye. Therefore, the worse-vision eye should not be neglected during the management of AMD.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Endpoints for clinical trials in ophthalmology

With the identification of novel targets, the number of interventional clinical trials in ophthalmology has increased. Visual acuity has for a long time been considered the gold standard endpoint for clinical trials, but in the recent years it became evident that other endpoints are required for many indications including geographic atrophy and inherited retinal disease. In glaucoma the currently available drugs were approved based on their IOP lowering capacity. Some recent findings do, however, indicate that at the same level of IOP reduction, not all drugs have the same effect on visual field progression. For neuroprotection trials in glaucoma, novel surrogate endpoints are required, which may either include functional or structural parameters or a combination of both. A number of potential surrogate endpoints for ophthalmology clinical trials have been identified, but their validation is complicated and requires solid scientific evidence. In this article we summarize candidates for clinical endpoints in ophthalmology with a focus on retinal disease and glaucoma. Functional and structural biomarkers, as well as quality of life measures are discussed, and their potential to serve as endpoints in pivotal trials is critically evaluated.

The management of neovascular age-related macular degeneration: A systematic literature review of patient-reported outcomes, patient mental health and caregiver burden

PURPOSE

The aim of this systematic literature review was to describe patient-reported outcomes, mental health and caregiver burden in patients with neovascular age-related macular degeneration (nAMD) treated with anti-vascular endothelial growth factor (VEGF) agents in routine clinical practice.

METHODS

Electronic searches were conducted in Embase and MEDLINE according to pre-defined criteria.

RESULTS

Of 856 records identified, 63 met inclusion criteria. Depression or depressive symptoms were reported in up to 42% of patients with nAMD. Of 25/63 (40%) studies evaluating quality of life (QoL) and using various tools, eight studies reported composite National Eye Institute Visual Functioning Questionnaire scores following anti-VEGF treatment. Of these, seven reported a statistically significant improvement at the earliest time point measured (Month 3-12) and approximately 50% reported sustained QoL benefits at 12 months. In studies comparing the attributed or different regimens, the most important factor from the patient's perspective was the likelihood that a particular regimen would maintain vision. There was a preference towards treat and extend, which was associated with a perceived reduction in patient and caregiver burden, compared to fixed dosing.

CONCLUSIONS

A coordinated holistic approach to patient care is key to optimizing patient well-being as well as visual outcomes. Further research regarding the patient-reported impact of nAMD management outside the trial setting (particularly international longitudinal studies) is warranted. Standardization of QoL studies would assist in establishing whether sustained QoL improvement, rather than prevention of QoL decline, should be a realistic expectation of treatment of nAMD in the longer term.

The NEI VFQ-25C: Calibrating Items in the National Eye Institute Visual Function Questionnaire-25 to Enable Comparison of Outcome Measures

Purpose

To improve the usefulness of the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25) by enabling estimation of measures on an invariant scale and comparisons between patients and across studies.

Methods

Datasets of baseline NEI VFQ-25 responses from nine studies (seven retina randomized trials, n = 2770; two low vision studies, n = 572) were combined. The method of successive dichotomizations was applied to patient ratings of the main NEI VFQ-25 and six supplemental items to estimate Rasch model parameters using the R package 'msd.' Calibrated item measures and rating category thresholds were estimated for the NEI VFQ-25, as well as for two domain-specific versions: the NEI VFQ-VF that includes only visual function items and the NEI VFQ-SE that includes only socioemotional items.

Results

Calibrated item measures were estimated from study participants (n = 3342) ranging in age from 19 to 103 years, with mean (SD) age of 69.3 (11) years and a mean logMAR visual acuity of 0.30 (Snellen 20/40). Item measure estimates had high precision (standard error range, 0.026-0.085 logit), but person measure estimates had lower precision (standard error range, 0.108-0.499 logit). Items were well targeted to most persons, but not to those with higher levels of function.

Conclusions

Calibrated item measures and rating category thresholds enable researchers and clinicians to estimate visual, socioemotional, and combined measures on an invariant scale using the NEI VFQ-25.

Translational Relevance

Applying NEI VFQ 25C calibrated item measures (software provided) to the NEI VFQ-25, users can estimate overall, visual, and socioemotional function measures for individual patients.

Biomarkers as Predictive Factors of Anti-VEGF Response

Age-related macular degeneration is the main cause of irreversible vision in developed countries, and intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections are the current gold standard treatment today. Although anti-VEGF treatment results in important improvements in the course of this disease, there is a considerable number of patients not responding to the standardized protocols. The knowledge of how a patient will respond or how frequently retreatment might be required would be vital in planning treatment schedules, saving both resource utilization and financial costs, but today, there is not an ideal biomarker to use as a predictive response to ranibizumab therapy. Whole blood and blood mononuclear cells are the samples most studied; however, few reports are available on other important biofluid samples for studying this disease, such as aqueous humor. Moreover, the great majority of studies carried out to date were focused on the search for SNPs in genes related to AMD risk factors, but miRNAs, proteomic and metabolomics studies have rarely been conducted in anti-VEGF-treated samples. Here, we propose that genomic, proteomic and/or metabolomic markers could be used not alone but in combination with other methods, such as specific clinic characteristics, to identify patients with a poor response to anti-VEGF treatment to establish patient-specific treatment plans.

Real-life patient journey in neovascular age-related macular degeneration: a narrative medicine analysis in the Italian setting

OBJECTIVES

To investigate the real-life experience of patients affected by neovascular age-related macular degeneration (nAMD), in the healthcare pathway for the management of the disease, using a "patient journey" and narrative method approach.

METHODS

The patient journey of subjects affected by nAMD was designed using a process-mapping methodology involving a team from 11 Italian centres. Subsequently, narratives were collected from nAMD patients and family members. The interviews were analyzed using the narrative medicine methodology.

RESULTS

Eleven specialized retina centres across Italy were involved and 205 narratives collected. In 29% of cases, patients underestimated their symptoms or attributed them to non-pathological causes, thus delaying the specialist consultation. The delay in accessing to care was due to a lack of awareness of this disease (50% of the participants didn't know what nAMD is) and to critical issues faced at first visit (long waiting lists, failed diagnosis, underestimation of the problem). Despite anti-VEGF therapies were perceived as effective in improving or stabilizing vision in 91% of narratives collected, 77% of patients still reduced or ceased daily activities such as reading and driving. Within the pathway of care there was not a multidisciplinary approach, and the patients were treated just by the ophthalmologist.

CONCLUSIONS

nAMD may significantly affect the quality of life of affected patients, both from a functional and psychological point of view. The narrative medicine approach highlights some critical points in the healthcare journey of nAMD patients and represents a useful background in implementing patient management algorithms and pathways of care.

The impact of advanced age-related macular degeneration on the National Eye Institute's Visual Function Questionnaire-25

PURPOSE

To assess visual function among patients diagnosed with age-related macular degeneration (AMD) by stage of disease and laterality.

METHODS

This is a cross-sectional cohort study of 739 AMD patients and their responses to the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25) at time of study enrolment. Patients with AMD were categorized into Early/Intermediate AMD and three groups of advanced AMD: (i) neovascular AMD (NV), (ii) geographic atrophy (GA) and (iii) Both Advanced forms. These three advanced stages were further stratified into unilateral or bilateral advanced disease. Mean composite scores and subscale scores for 12 different areas were based on a 100-point scale with the lowest and highest possible scores set at 0 and 100, respectively. Scores for the advanced AMD groups were compared with Early/Intermediate AMD using general linear modelling.

RESULTS

A total of 739 AMD patients (294 Early/Intermediate, 115 GA, 168 NVAMD and 162 Both Advanced) were included in the analysis. Mean composite scores were highest among Early/Intermediate patients (89.9), followed by patients diagnosed with unilateral disease in the Both Advanced (88.0) and NV (86.1) groups. Mean composite scores were similar for bilateral NV (82.9) and unilateral GA (81.7), and mean scores were lowest for the bilateral GA (71.3) and bilateral Both Advanced (68.5) groups. In general, this pattern persisted across the twelve subscales as well. Subscale scores ranged from a low of 35.1 for driving among bilateral Both Advanced patients to a high of 99.2 for colour vision among patients with unilateral Both Advanced. Overall, patients with unilateral advanced disease consistently had higher mean scores than their bilateral counterparts. The largest difference was 19.5 composite score points between the unilateral and bilateral Both Advanced groups, there was a difference of 10.4 points between the GA groups, and a relatively small difference of 3.2 points between the NV groups.

CONCLUSIONS

We found large differences in visual function as reported from the VFQ-25 across the different types of advanced stage AMD groups and number of eyes affected with advanced AMD. These findings demonstrate the importance of accounting for the type and number of eyes affected by advanced stage AMD.

Associations between adult attachment and vision-related quality of life in visually impaired individuals

PURPOSE

An attachment theory framework approach may allow insight into how social and psychosocial factors interact to impact vision-related quality of life (QoL). In this pilot study, we investigated potential associations between adult attachment style and visual function QoL of visually impaired individuals.

METHODS

We recruited 38 visually impaired individuals (15 females, 23 males; 51.8 ± 16.0 years). Visual function measures included distance and near visual acuity (VA) and contrast sensitivity. All participants completed: the 25-item National Eye Institute Visual Functioning Questionnaire-25 (NEI-VFQ 25) and the Experiences in Close Relationships-Relationships Structures questionnaire.

RESULTS

Presenting conditions included inherited retinal dystrophy (n = 10), nystagmus (n = 9), glaucoma (n = 7) and other eye conditions (n = 12). There was a statistically significant negative correlation between the NEI-VFQ-25 composite score (45.5 ± 14.7) and attachment-related anxiety (r = -0.352, p = 0.033). The latter correlation still held when controlling for participants' level of vision (r = -0.352, p = 0.035). Despite the range of conditions and wide age range, these were not significantly correlated with any variable of interest in the current study.

CONCLUSION

Attachment-related anxiety ought to be taken into account when managing a visually impaired individual. Attachment-based approaches could be used to improve access to support services for visually impaired individuals, as well as self-management of their condition.

Multimodal Evaluation of Visual Function in Geographic Atrophy versus Normal Eyes

Purpose

To comprehensively evaluate visual function in eyes with geographic atrophy (GA) as compared to normal eyes.

Patients and Methods

Sixty-three eyes from 63 patients ≥50 years old were recruited for this observational study; 31 were identified as normal macular health eyes and 32 with GA. Visual function was tested with best corrected visual acuity (BCVA), low luminance visual acuity (LLVA), low luminance deficit (LLD), reading speed, macular integrity microperimetry, fixation stability, and contrast sensitivity function (CSF). Anatomic function was evaluated with spectral-domain optical coherence tomography (SD-OCT) and fundus autofluorescence (FAF). Quality of life and vision were assessed with the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25).

Results

Visual function and quality of life are reduced in patients with GA. Moderate and strong correlations in the GA group were found between maximum reading speed (r = 0.787) (p˂0.01), CS spatial frequency 3 cpd (r = 0.441) (p˂0.05), CS spatial frequency 6 cpd (r = 0.524) (p˂0.01), fixation P1 (r = 0.379) (p˂0.05), macular sensitivity (r = 0.484) (p˂0.05) and atrophic area (r = -0.689) (p˂0.01), and the VFQ-25 composite score.

Conclusion

The decreased visual function is reflected in a poor quality of life in patients with GA. Reading speed, contrast sensitivity, fixation, and macular sensitivity are strongly associated with vision-related quality of life. The results suggest the importance of the reading letter size in patients with GA. Microperimetry and reading speed are useful tools to better assess visual impairment in patients with GA.

Impacts of impaired face perception on social interactions and quality of life in age-related macular degeneration: A qualitative study and new community resources

Aims

Previous studies and community information about everyday difficulties in age-related macular degeneration (AMD) have focussed on domains such as reading and driving. Here, we provide the first in-depth examination of how impaired face perception impacts social interactions and quality of life in AMD. We also develop a Faces and Social Life in AMD brochure and information sheet, plus accompanying conversation starter, aimed at AMD patients and those who interact with them (family, friends, nursing home staff).

Method

Semi-structured face-to-face interviews were conducted with 21 AMD patients covering the full range from mild vision loss to legally blind. Thematic analysis was used to explore the range of patient experiences.

Results

Patients reported faces appeared blurred and/or distorted. They described recurrent failures to recognise others' identity, facial expressions and emotional states, plus failures of alternative non-face strategies (e.g., hairstyle, voice). They reported failures to follow social nuances (e.g., to pick up that someone was joking), and feelings of missing out ('I can't join in'). Concern about offending others (e.g., by unintentionally ignoring them) was common, as were concerns of appearing fraudulent ('Other people don't understand'). Many reported social disengagement. Many reported specifically face-perception-related reductions in social life, confidence, and quality of life. All effects were observed even with only mild vision loss. Patients endorsed the value of our Faces and Social Life in AMD Information Sheet, developed from the interview results, and supported future technological assistance (digital image enhancement).

Conclusion

Poor face perception in AMD is an important domain contributing to impaired social interactions and quality of life. This domain should be directly assessed in quantitative quality of life measures, and in resources designed to improve community understanding. The identity-related social difficulties mirror those in prosopagnosia, of cortical rather than retinal origin, implying findings may generalise to all low-vision disorders.

Vision related quality of life in patients with type 2 diabetes in the EUROCONDOR trial

To evaluate vision related quality of life in the patients enrolled in The European Consortium for the Early Treatment of Diabetic Retinopathy, a clinical trial on prevention of diabetic retinopathy. Four-hundred-forty-nine patients, 153 women, with type 2 Diabetes and no or mild diabetic retinopathy were enrolled in a 2-year multicenter randomized controlled trial. The 25-item National Eye Institute Visual Functioning Questionnaire was used to explore 12 subscales of vision related quality of life. The patients were 62.8 ± 6.7 years old and had 11.1 ± 5.6 years known disease duration. Diabetic retinopathy was absent in 193 (43.0 %) and mild in 256 (57.0 %). Patients without diabetic retinopathy were older, had shorter diabetes duration and used less insulin and glucose-lowering agents but did not differ by gender, best corrected visual acuity or any subscale, except vision specific mental health and vision specific role difficulties. Patients with reduced retinal thickness at the ganglion cell layer (n = 36) did not differ for diabetic retinopathy but were older, had lower best corrected visual acuity and worse scores for ocular pain, color vision and peripheral vision. On multivariable analysis, worse scores for general vision remained associated with reduced retinal thickness, diabetes duration and best corrected visual acuity, and scores for visual specific mental health with diabetic retinopathy and lower best corrected visual acuity. Visual specific role difficulties were only associated with reduced best corrected visual acuity. Scores for driving decreased among females, with worsening of Hemoglobin A1c and best corrected visual acuity. Color vision depended only on reduced retinal thickness, and peripheral vision on both reduced thickness and best corrected visual acuity. The National Eye Institute Visual Functioning Questionnaire could detect subtle changes in patients' perception of visual function, despite absent/minimal diabetic retinopathy.

Risk Factors for Poor Quality of Life among Patients with Age-Related Macular Degeneration

PURPOSE

The purpose of this study was to evaluate the quality of life in patients with age-related macular degeneration (AMD) and compare it with that of healthy controls. Additionally, our study aims to investigate the possible risk factors for poor quality of life in AMD patients.

METHODS

Participants in the study were 114 patients with AMD, 63 male and 51 female, mean-aged 76.5 ± 6.1 years. Demographic data, lifestyle factors, and medical history were recorded. All patients underwent a routine examination for AMD, including best-corrected visual acuity measurement, dilated fundoscopy and optical coherence tomography, and completed three questionnaires assessing quality of life (SF-36, EQ-5D, NEI VFQ-25). In addition, 100 controls, adjusted for gender and age, were included in the study. Risk factors for quality of life in AMD patients were investigated. Univariate analysis was performed using SPSS 22.0.

RESULTS

Patients with AMD scored lower in vision- and health-related quality-of-life questionnaires compared to controls. Risk factors associated with quality of life in patients with AMD were found to be the female gender, alcohol consumption, the presence of hypertension, diabetes mellitus, cardiovascular diseases, myosceletal problems, migraine, anxiety/depression, subretinal or intraretinal fluid, pigment epithelium detachment, previous treatment for AMD, visual acuity, the stage of the disease, and the integrity of the ellipsoid zone.

CONCLUSION

Patients with AMD presented lower quality of life in comparison with controls. Potential risk factors should be taken into account and clinicians should thus focus on the most vulnerable subgroups.

Comparing half-dose photodynamic therapy with high-density subthreshold micropulse laser treatment in patients with chronic central serous chorioretinopathy (the PLACE trial): study protocol for a randomized controlled trial

Background

Chronic central serous chorioretinopathy (cCSC) is an eye disease characterized by an accumulation of serous fluid under the retina. It is postulated that this fluid accumulation results from hyperpermeability and swelling of the choroid, the underlying vascular tissue of the eye, causing a dysfunction of the retinal pigment epithelium. This fluid accumulation causes neuroretinal detachment. A prolonged neuroretinal detachment in the macula can lead to permanent vision loss. Therefore, treatment is aimed primarily at achieving resolution of subretinal fluid, preferably within the first 4 months after diagnosis of the disease. A broad spectrum of treatment modalities has been investigated in cCSC, but no consensus exists on the optimal treatment of cCSC. Currently, photodynamic therapy (PDT) and high-density subthreshold micropulse laser treatment (HSML) are among the most frequently cited treatments in obtaining successful neuroretinal reattachment.

Methods/Design

This is a randomized, controlled, open-label, multicenter trial comparing the efficacy of half-dose PDT to HSML in treating patients with cCSC. A total of 156 patients will be recruited, 78 patients in each treatment arm, with a maximum follow-up duration of 8 months after the first treatment. A complete ophthalmological examination with vision-related quality of life (NEI VFQ-25) and stress questionnaires, will be performed at baseline, 6 to 8 weeks after the first treatment, 6 to 8 weeks after a second treatment (if necessary), and at the final follow-up visit at 7 to 8 months after the first treatment. Treatment visits will be scheduled within 3 weeks after the baseline visit, and within 3 weeks after the first control visit, if a second treatment is required.

Discussion

Both half-dose PDT and HSML may be effective treatments in cCSC, but because of the lack of prospective randomized controlled trials, which treatment should be the first choice remains unclear. The aim of this study is to compare the efficacy of half-dose PDT to HSML. The primary endpoint to evaluate efficacy will be a complete absence of subretinal fluid on optical coherence tomography after treatment. Secondary functional endpoints include change in Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity, retinal sensitivity on microperimetry, and NEI VFQ-25 questionnaire of visual functioning.

Registration number Institutional Review Board (CMO Arnhem-Nijmegen, the Netherlands): 2013/203 NL nr.: 41266.091.13

Trial registration

ClinicalTrials.gov identifier: NCT01797861. Date of registration: 21 February 2013.

Threshold levels of visual field and acuity loss related to significant decreases in the quality of life and emotional states of patients with retinitis pigmentosa

INTRODUCTION

Retinitis pigmentosa (RP) is an inherited retinal disorder, characterized by photoreceptor degeneration inducing progressive vision loss. This study evaluates its impact on quality of life (QOL) and emotional states of patients affected by RP.

METHODS

A cross-sectional study was conducted on 60 RP patients diagnosed with rod-cone dystrophy and on 20 control subjects. The RP population has been divided into 3 groups according to visual field (VF) and visual acuity (VA) impairments. Concurrently, scores of self-reported QOL (25-item National Eye Institute Visual Functioning Questionnaire) and of the Hospital Anxiety and Depression Scale for anxiety/depression assessments were collected.

RESULTS

For the QOL composite score, we noticed consistent differences between all VF and VA affected groups and their control group. We also found significant differences between both the most affected VF group (VF1: ØVF <20°) and VA group (VA1: VA <0.3) compared to other VF and VA groups. For anxiety/depression scores, consistent differences have been found between the control group and VF1 and VA1, respectively.

CONCLUSIONS

This work determines that, for RP patients, a significant QOL and emotional state deterioration correlates with a residual VF diameter below 20° and a VA lower than 0.3. It introduces, for the first time, thresholds to be used in visual restoration or visual preservation therapies to improve QOL of RP patients.

Patient-reported outcomes in randomised controlled trials on age-related macular degeneration

BACKGROUND/AIMS

The purpose of this systematic review was to identify the frequency and type of patient-reported outcome measures (PROMs) used in recent randomised controlled trials (RCTs) for age-related macular degeneration (AMD).

METHODS

The authors conducted a systematic search between January 2010 and November 2013 in MEDLINE, EMBASE, Scopus, Cochrane Library (Central) and the clinical trials registries (http://www.controlled-trials.com and http://www.ClinicalTrials.gov) according to defined inclusion criteria (RCTs on AMD in English). Two independent reviewers evaluated studies for inclusion. One reviewer extracted data of included studies, and a second masked reviewer assessed 10% to confirm accuracy in data collection. Reference lists of included papers and appendices of relevant Cochrane systematic reviews were scanned to identify other relevant RCTs. Information collected on extracted outcomes was analysed using descriptive statistics.

RESULTS

Literature and registry search yielded 3816 abstracts of journal articles and 493 records from trial registries. A total of 177 RCTs were deemed to have met inclusion criteria. Of the 858 outcomes reported, 38 outcomes were identified as PROMs (4.4%). Of the 177 RCTs examined, PROMs were used in 25 trials (14.1%). The National Eye Institute Visual Function Questionnaire-25 was the most frequently used PROM instrument (64% of RCTs with PROMs included).

CONCLUSIONS

This review highlights that a small proportion of AMD RCTs included PROMs as outcome measures and that there was a variety in the instruments used.

TRIAL REGISTRATION NUMBER

The systematic review was registered in the PROSPERO database for systematic reviews, registration number CRD42014010040.

Human embryonic stem cell-derived retinal pigment epithelium in patients with age-related macular degeneration and Stargardt's macular dystrophy: follow-up of two open-label phase 1/2 studies

BACKGROUND

Since they were first derived more than three decades ago, embryonic stem cells have been proposed as a source of replacement cells in regenerative medicine, but their plasticity and unlimited capacity for self-renewal raises concerns about their safety, including tumour formation ability, potential immune rejection, and the risk of differentiating into unwanted cell types. We report the medium-term to long-term safety of cells derived from human embryonic stem cells (hESC) transplanted into patients.

METHODS

In the USA, two prospective phase 1/2 studies were done to assess the primary endpoints safety and tolerability of subretinal transplantation of hESC-derived retinal pigment epithelium in nine patients with Stargardt's macular dystrophy (age >18 years) and nine with atrophic age-related macular degeneration (age >55 years). Three dose cohorts (50,000, 100,000, and 150,000 cells) were treated for each eye disorder. Transplanted patients were followed up for a median of 22 months by use of serial systemic, ophthalmic, and imaging examinations. The studies are registered with ClinicalTrials.gov, numbers NCT01345006 (Stargardt's macular dystrophy) and NCT01344993 (age-related macular degeneration).

FINDINGS

There was no evidence of adverse proliferation, rejection, or serious ocular or systemic safety issues related to the transplanted tissue. Adverse events were associated with vitreoretinal surgery and immunosuppression. 13 (72%) of 18 patients had patches of increasing subretinal pigmentation consistent with transplanted retinal pigment epithelium. Best-corrected visual acuity, monitored as part of the safety protocol, improved in ten eyes, improved or remained the same in seven eyes, and decreased by more than ten letters in one eye, whereas the untreated fellow eyes did not show similar improvements in visual acuity. Vision-related quality-of-life measures increased for general and peripheral vision, and near and distance activities, improving by 16-25 points 3-12 months after transplantation in patients with atrophic age-related macular degeneration and 8-20 points in patients with Stargardt's macular dystrophy.

INTERPRETATION

The results of this study provide the first evidence of the medium-term to long-term safety, graft survival, and possible biological activity of pluripotent stem cell progeny in individuals with any disease. Our results suggest that hESC-derived cells could provide a potentially safe new source of cells for the treatment of various unmet medical disorders requiring tissue repair or replacement.

FUNDING

Advanced Cell Technology.

Predictors of anti-VEGF treatment response in neovascular age-related macular degeneration

Currently available evidence on predictors of anti-vascular endothelial growth factor (VEGF) treatment response in neovascular age-related macular degeneration was reviewed. No meta-analysis of results is possible because of a lack of controlled and randomized trials, varying treatment regimes and outcome measures used, as well as suboptimal reporting. For genetic factors, most evidence to date has been generated for single nucleotide polymorphisms (SNPs) in the complement factor H (CFH), and VEGF-A genes. Just under half of the SNPs assessed in the CFH gene and 15% of the SNPs assessed in the VEGF gene were found to be associated with visual outcomes or the number of injections required during follow-up. Some evidence suggests association of worse treatment outcomes as well as a younger age at treatment onset with an increasing number of risk alleles in known risk genes (CFH and ARMS2/HTRA1) and polymorphisms in the VEGF-A gene. Clinical factors such as higher age, a better visual acuity (VA), a larger choroidal neovascularization (CNV) lesion at baseline, and a delay between symptom onset and initiation of treatment of more than 3 weeks also impact outcomes. Conversely, a worse acuity at baseline predicted more gain in vision. Overall, patients presenting with good acuity at baseline were more likely to have good VA at follow up, but the gain afforded by treatment was impacted by a ceiling effect. Most available evidence suggests a strong association of clinical factors such as age, baseline VA, and CNV lesion size with anti-VEGF treatment outcomes. No behavioral factors such as smoking influence treatment outcomes. Based on the studies conducted so far, the evidence suggests that underlying genotype of known AMD risk associated genes or of the VEGF-A gene have a limited effect, whereas presenting clinical factors appear to be more important in determining treatment outcomes.

Psychometric analyses to improve the Dutch ICF Activity Inventory

PURPOSE

In the past, rehabilitation centers for the visually impaired used unstructured or semistructured methods to assess rehabilitation needs of their patients. Recently, an extensive instrument, the Dutch ICF Activity Inventory (D-AI), was developed to systematically investigate rehabilitation needs of visually impaired adults and to evaluate rehabilitation outcomes. The purpose of this study was to investigate the underlying factor structure and other psychometric properties to shorten and improve the D-AI.

METHODS

The D-AI was administered to 241 visually impaired persons who recently enrolled in a multidisciplinary rehabilitation center. The D-AI uses graded scores to assess the importance and difficulty of 65 rehabilitation goals. For high-priority goals (e.g., daily meal preparation), the difficulty of underlying tasks (e.g., read recipes, cut vegetables) was assessed. To reduce underlying task items (>950), descriptive statistics were investigated and factor analyses were performed for several goals. The internal consistency reliability and test-retest reliability of the D-AI were investigated by calculating Cronbach α and Cohen (weighted) κ. Finally, consensus-based discussions were used to shorten and improve the D-AI.

RESULTS

Except for one goal, factor analysis model parameters were at least reasonable. Internal consistency reliability was satisfactory (range, 0.74 to 0.93). In total, 60% of the 65 goal importance items and 84.4% of the goal difficulty items showed moderate to almost perfect κ values (≥0.40). After consensus-based discussions, a new D-AI was produced, containing 48 goals and less than 500 tasks.

CONCLUSIONS

The analyses were an important step in the validation process of the D-AI and to develop a more feasible assessment tool to investigate rehabilitation needs of visually impaired persons in a systematic way. The D-AI is currently implemented in all Dutch rehabilitation centers serving all visually impaired adults with various rehabilitation needs.

Driving habits in older patients with central vision loss

OBJECTIVE

To determine if central visual loss is associated with driving cessation, driving restriction, or other-driver preference.

DESIGN

Cross-sectional study.

PARTICIPANTS

Sixty-four subjects with bilateral visual loss (<20/32 in better eye) or severe unilateral visual loss (<20/200) from age-related macular degeneration (AMD) and 58 normally sighted controls between 60 and 80 years of age.

METHODS

Participants self-reported driving habits. Other-driver preference was defined as preferring that another drive when there is more than 1 driver in the car. Subjects reporting 2 or more driving limitations were considered to have restricted their driving.

MAIN OUTCOME MEASURES

Self-reported driving cessation, other-driver preference, and driving restriction.

RESULTS

Age-related macular degeneration subjects were older (74.7 vs. 69.7 years), had worse visual acuity (VA; mean better-eye VA, 0.43 vs. 0.08 logarithm of minimum angle of resolution [logMAR]) and contrast sensitivity (CS; 1.4 vs. 1.9 log units of CS [logCS]), and were more likely to be white when compared with controls (P<0.001 for all). Drivers with AMD-related vision loss were more likely to avoid driving over longer distances, beyond 1 hour, at night, and in unfamiliar conditions (P < 0.05 for all). In multivariate models, driving cessation was associated with worse better-eye VA (odds ratio [OR], 1.5 per 1-line decrement in VA; P<0.001) and worse binocular CS (OR, 1.36 per 0.1 logCS increment; P = 0.005); however, AMD group status was not associated with driving cessation (OR, 1.9; P = 0.35). Factors predicting driving restriction were AMD (OR, 9.0; P = 0.004), worse vision (OR, 2.5 per line of VA loss; P<0.001), lower CS (OR, 2.2 per 0.1-logCS increment; P<0.001), and female gender (OR, 27.9; P = 0.002). Other-driver preference was more common with worse vision (OR, 1.6 per 0.1-logMAR increment; P = 0.003), female gender (OR, 4.5; P = 0.02), and being married (OR, 3.8; P = 0.04).

CONCLUSIONS

Most patients with AMD-related central vision loss continue to drive, but demonstrate significant driving restrictions, especially with more severe VA and CS loss. Future work should determine which driving adaptations the visually impaired best balance safety and independence.

Visual acuity changes in patients with leber congenital amaurosis and mutations in CEP290

OBJECTIVE

To evaluate changes in visual acuity (VA) over time in patients with Leber congenital amaurosis (LCA) and mutations in the CEP290 gene.

METHODS

Visual acuity was determined at the initial and most recent visits of 43 patients with LCA and CEP290 mutations. The main outcome measures included the best-corrected VA at the initial and most recent visits, as well as the correlation between age and VA.

RESULTS

At the initial visit, 14 patients had measurable chart VA in the better-seeing eye, 25 patients had nonmeasurable chart VA, and 4 young patients did not have VA assessed. At the most recent visit, 15 patients had measurable chart VA and 28 had nonmeasurable chart VA. The average interval between the 2 visits was 10.4 years (range, 2-47 years). For patients with measurable chart VA, the median logMAR value at the initial visit (0.75; range, 0.10-2.30) and at the most recent visit (0.70; range, 0.10-2.00) did not differ significantly (P> .05). There was no significant relationship between VA and age.

CONCLUSIONS

Patients with LCA and CEP290 mutations had a wide spectrum of VA that was not related to age or length of follow-up. Severe VA loss was observed in most, but not all, patients in the first decade. These data will help clinicians provide counseling on VA changes in patients with CEP290 mutations and could be of value for future treatment trials.

Pars plana vitrectomy for disturbing primary vitreous floaters: clinical outcome and patient satisfaction

BACKGROUND

Primary vitreous floaters can be highly bothersome in some patients. In the case of persistently bothersome floaters, pars plana vitrectomy may be the most effective treatment. The aim of this study is to evaluate the incidence of complications, and patient satisfaction, after pars plana vitrectomy for disabling primary vitreous opacities.

METHODS

We included a total of 110 eyes that underwent pars plana vitrectomy between February 1998 and August 2010. Fifty-seven eyes (51.8%) underwent 20-gauge vitrectomy, whereas 53 eyes (48.2%) underwent 23-gauge vitrectomy. In a retrospective manner, we assessed intraoperative and postoperative complications. There was a considerable range of time between surgery and questionnaire (range: 4-136 months). Patient satisfaction was assessed by a questionnaire based on a modified NEI VFQ-25 questionnaire.

RESULTS

A retinal detachment occurred in 10.9% of cases, and the incidence did not differ significantly between the 20-gauge and 23-gauge vitrectomy groups. In 4.5% of the eyes, a retinal detachment developed within the first 3 months, and 6.4% occurred later in the postoperative period. Cystoid macular edema occurred in 5.5%, and an epiretinal membrane was seen postoperatively in 3.6% of cases. Development of glaucoma requiring glaucoma surgery, a macular hole, and postoperative scotoma, each occurred in 0.9% of cases. No cases of endophthalmitis occurred. Eighty-five percent of patients were satisfied or very satisfied with the results of the vitrectomy. Eighty-four percent of all patients were completely cured from their troublesome vitreous floaters, and an additional 9.3% of patients were less troubled by vitreous floaters. Ten patients (9.3%) were dissatisfied, and six of these patients (5.6%) had a serious complication that resulted in permanent visual loss.

CONCLUSIONS

Pars plana vitrectomy is an effective approach to treat primary vitreous floaters, resulting in a high rate of patient satisfaction. Postoperative complications may be more frequent than previously reported, so patients should be well-informed about the complication rate before reaching informed consent about this surgical intervention. Additional preventive measures should be considered to reduce this complication rate.

[Measurement of glaucoma-specific functionality with the GQL-15 and correlation with parameters of visual function]

INTRODUCTION

Glaucoma is one of the leading causes of irreversible blindness worldwide and can have a significant impact on patient quality of life and vision-related functioning. The Glaucoma Quality of Life 15 (GQL-15) questionnaire is a disease-specific instrument to evaluate and quantify functional impairment of patients with glaucoma. This study evaluated the German version of the GQL-15 including correlations with perimetric parameters.

METHODS

A German version of the GQL-15 containing 15 items was developed and evaluated in 98 patients with glaucoma in different stages of the disease. The GQL-15 results were correlated with the perimetric parameters mean deviation (MD) and pattern standard deviation (PSD) of the better and worse eye. Classical and probabilistic test analyses (Rasch model) were performed.

RESULTS

The mean GQL-15 value was 77.3 ± 21.7 (SD) and most items of the GQL-15 correlated significantly with the MD of the worse eye (r = -0.416; p = 0.0014) and the better eye (r = -0.304; p = 0.02). There was also a highly significant correlation between glaucoma-specific QoL and visual acuity. A short version containing nine items yielding a higher psychometric performance can also be used.

CONCLUSIONS

The German version of the GQL-15 is a potent instrument to evaluate impairment in vision-specific functioning of patients with glaucoma. The GQL-15 values are better correlated with the sensitivity of the eye with the more severe glaucomatous damage. The data can help for a better understanding of individual patient impairment to improve medical advice and therapy of patients with glaucoma.

Visual function and quality of life in pseudophakic patients before and after capsulotomy

PURPOSE

To assess the correlation between visual acuity, visual function, and health-related quality of life before and after neodymium:YAG laser posterior capsulotomy.

METHODS

A total of 150 patients with posterior capsule opacification (PCO) were examined before and after capsulotomy. Ocular examination, visual acuity, patient reports of satisfaction with vision, and disease-specific (VF-14 Index of Visual Functions) and generic (EuroQol: EQ-5D) outcomes were measured at baseline and 3 weeks after treatment.

RESULTS

After capsulotomy, patients showed significant improvements in binocular visual acuity, VF-14 index, satisfaction with vision, and EQ-5D measures. The average gains in visual function and quality of life were apparent in groups with good visual outcome and poor visual outcome. The VF-14 score improvement was moderately correlated with the EuroQol Visual Analogue Scale score improvement, showing stronger correlations with changes in self-reported satisfaction with vision than did gains in binocular visual acuity.

CONCLUSIONS

Measuring of the outcomes of capsulotomy by clinical indicators alone may underestimate the overall benefits of treatment. Visual acuity in conjunction with visual function and health-related quality of life questionnaires will likely prove to be better indicators of the need for and outcome of capsulotomy.

Re-evaluating a vision-related quality of life questionnaire with item response theory (IRT) and differential item functioning (DIF) analyses

BACKGROUND

For the Low Vision Quality Of Life questionnaire (LVQOL) it is unknown whether the psychometric properties are satisfactory when an item response theory (IRT) perspective is considered. This study evaluates some essential psychometric properties of the LVQOL questionnaire in an IRT model, and investigates differential item functioning (DIF).

METHODS

Cross-sectional data were used from an observational study among visually-impaired patients (n = 296). Calibration was performed for every dimension of the LVQOL in the graded response model. Item goodness-of-fit was assessed with the S-X(2)-test. DIF was assessed on relevant background variables (i.e. age, gender, visual acuity, eye condition, rehabilitation type and administration type) with likelihood-ratio tests for DIF. The magnitude of DIF was interpreted by assessing the largest difference in expected scores between subgroups. Measurement precision was assessed by presenting test information curves; reliability with the index of subject separation.

RESULTS

All items of the LVQOL dimensions fitted the model. There was significant DIF on several items. For two items the maximum difference between expected scores exceeded one point, and DIF was found on multiple relevant background variables. Item 1 'Vision in general' from the "Adjustment" dimension and item 24 'Using tools' from the "Reading and fine work" dimension were removed. Test information was highest for the "Reading and fine work" dimension. Indices for subject separation ranged from 0.83 to 0.94.

CONCLUSIONS

The items of the LVQOL showed satisfactory item fit to the graded response model; however, two items were removed because of DIF. The adapted LVQOL with 21 items is DIF-free and therefore seems highly appropriate for use in heterogeneous populations of visually impaired patients.

[Quality of life of visually impaired adults after low-vision intervention: a pilot study]

OBJECTIVE

To demonstrate the benefits of a low-vision intervention upon the quality of life of visually disabled adults.

METHODS

The survey was proposed to patients who sought a low-vision intervention at the Colmar and Strasbourg hospital centres over a period of 9 months. Patients in agreement with the survey were asked to complete the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ25) in interview format by telephone, once they had attended the first meeting and again 2 months after the end of the low-vision intervention.

RESULTS

The low-vision intervention led to overall improvement as judged by the 25 items of the questionnaire. Some items involving visual function and psychological issues showed significant benefits: the patients reported a more optimistic score concerning their general vision, described better nearby activities, and felt a bit more autonomous.

CONCLUSION

More than mainstream psychological counselling, low-vision services help patients cope with visual disabilities during their daily life. The low-vision intervention improves physical and technical issues necessary to retaining autonomy in daily life.

Metric properties of the MacDQoL, individualized macular-disease-specific quality of life instrument, and newly identified subscales in French, German, Italian, and American populations

OBJECTIVES

The aims of this analysis were to confirm the UK results in other countries and to explore the possibility of subscales of the 25-Item Macular disease Dependent Quality of Life (MacDQoL) questionnaire.

METHODS

Two clinical studies were pooled. Principal components analyses (Varimax) were conducted on baseline data from each country and from all combined. Factorial structures were compared between countries, and Cronbach alpha values were used to identify item clusters. Four groups of patients were created according to visual acuity (VA) in the best eye (BE < 10/20; BE ≥ 10/20) and worst eye (WE < 10/100; WE ≥ 10/100). These groups were used to investigate (analysis of variance) the sensitivity of MacDQoL to VA impairment and to compare it with the NEI-VFQ-25 generic visual function questionnaire.

RESULTS

A total of 797 patients (mean age 76.8 years; 55.8% women) had wet age-related macular degeneration (AMD). Strong correlations between the MacDQoL items (r > 0.48) and factor loadings > 0.49 on a forced one-factor analysis supported the use of an average weighted impact score. Four constructs (Cronbach alpha > 0.8) were derived, represented by the labels: Essential tasks, Family/social life, Activities/capabilities, and Embarrassment. The structure did not differ among the four countries involved, except one item (Finance), which has been excluded. Patients with BE VA <10/20 and WE VA <10/100 produced significantly worse overall scores than those with BE VA >10/20 and WE VA >10/100 (MacDQoL P < 0.0001; NEI-VFQ-25 P < 0.0001).

CONCLUSIONS

The analysis confirmed the metric properties of the MacDQoL. The MacDQoL offers a broad individualized measure of the impact of MD on quality of life.

Reliability and validity of abbreviated surveys derived from the National Eye Institute Visual Function Questionnaire: the study of osteoporotic fractures

PURPOSE

To test the reliability and validity of questionnaires shortened from the National Eye Institute 25-item Vision Function Questionnaire (NEI VFQ-25).

DESIGN

Cross-sectional, multicenter cohort study.

METHODS

Reliability was assessed by Cronbach alpha coefficients. Validity was evaluated by studying the association of vision-targeted quality-of-life composite scores with objective visual function measurements. A total of 5482 women between the ages of 65 and 100 years participated in the year-10 clinic visit in the Study of Osteoporotic Fractures (SOF). A total of 3631 women with complete data were included in the visual acuity (VA) and visual field (VF) analyses of the 9-item NEI VFQ (NEI VFQ-9), which is defined for those who care to drive, and a total of 5311 women with complete data were included in the VA and VF in the analyses of the 8-item NEI VFQ (NEI VFQ-8). To assess differences in prevalent eye diseases, which were ascertained for a random sample of SOF participants, 853 and 1237 women were included in the NEI VFQ-9 and the NEI VFQ-8 analyses, respectively.

RESULTS

The Cronbach alpha coefficient for the NEI VFQ-9 scale was 0.83, and that of the NEI VFQ-8 was 0.84. Using both questionnaires, women with VA worse than 20/40 had lower composite scores compared with those with VA of 20/40 or better (P < .001). Participants with mild, moderate, and severe binocular VF loss had lower composite scores compared with those with no binocular VF loss (P < .001). Compared with women without chronic eye diseases in both eyes, women with at least 1 chronic eye disease in at least 1 eye had lower composite scores.

CONCLUSIONS

Both questionnaires showed high reliability across items and validity with respect to clinical markers of eye disease. Future research should compare the properties of these shortened surveys with those of the NEI VFQ-25.

Additional psychometric information and vision-specific questionnaires are available for age-related macular degeneration

PURPOSE

To present psychometric information and studies dealing with questionnaires for age-related macular degeneration (AMD) and visually impaired patients in addition to the study by Finger et al. "Quality of life in AMD: a review of available vision-specific psychometric tools". We propose that their literature search should not have focused solely on the specific eye disease AMD.

METHODS

The literature search was partly replicated (PubMed) by using "visual impairment" instead of "macular degeneration" as free text words. Psychometric information was obtained from the additional studies. Preliminary results from a differential item functioning (DIF) analysis used to examine the relationship between item responses on the Vision-related quality of life Core Measure (VCM1) of AMD patients versus patients with other eye conditions are discussed.

RESULTS

Eight studies of visually impaired patient populations, including AMD patients, are discussed, with psychometric information from six vision-specific questionnaires. The VCM1 items did not present DIF, which means that the items were equally interpreted by all patients.

CONCLUSIONS

The results on DIF and the additional studies presented here confirm that a specific eye disorder is of minor importance in the choice of a vision-specific questionnaire or, in this case, a literature search.