Responsiveness of the National Eye Institute Refractive Error Quality of Life instrument to surgical correction of refractive error

Health-related quality of life measurements in children and adolescents with refractive errors: A scoping review

Background

Refractive errors, particularly myopia, are the leading visual disorders worldwide, significantly affecting the quality of life (QOL) even after correction. This scoping review focuses on health-related quality of life (HRQOL) measurements for children and adolescents with refractive errors.

Main text

We explored generic and disease-specific HRQOL tools, examining their content, psychometric properties, and the impact of various interventions on QOL. Two English databases-PubMed, Embase, and one Chinese database, CNKI, were searched for relevant studies published from January 2001 to October 2023. Inclusion criteria encompassed studies using standardized instruments to assess the QOL of children aged 0-18 with refractive errors. The review compares prevalent HRQOL measurements, analyzes children's refractive error assessments, and discusses intervention effects on patient QOL.

Conclusions

The study underlines the necessity of developing disease-specific QOL instruments for very young children and serves as a practical guide for researchers in this field. The findings advocate for a targeted approach in HRQOL assessment among the pediatric population, identifying critical gaps in current methodologies.

Myopia control: Seeing beyond efficacy

SIGNIFICANCE

The availability of a range of effective myopia control modalities enables the clinician to exercise judgment when discussing the treatment plan with the patient and their parents. This article outlines important considerations beyond efficacy.Clinically meaningful myopia control may be attained with some spectacle lenses, select soft contact lenses, some concentrations of atropine, and overnight orthokeratology. Given that satisfactory efficacy can be achieved with a range of modalities, other factors should be considered when deciding upon the best intervention for a given child. Four key factors-compliance, quality of vision, quality of life, and safety-are discussed in this review. Compliance directly impacts efficacy regardless of the modality and is the most important consideration, as it is influenced by quality of vision and comfort. Daily disposal myopia control contact lenses and overnight orthokeratology are generally associated with high compliance, provide better vision-related quality of life than spectacles, and carry a very low risk when used appropriately. A further benefit of overnight orthokeratology is the elimination of a need for optical correction during the day.

Comparison of Functional Vision and Eye-Related Quality of Life between Myopic Children Treated with Orthokeratology and Single-Vision Spectacles in Southern China

Objective

To compare eye-related quality of life between Chinese children wearing orthokeratology (OK) contact lenses and single-vision spectacles (SVS) using the Pediatric Eye Questionnaire (PedEyeQ) and to evaluate the impact of different myopia correction methods on children and their parents.

Methods

Children aged 12-17 years and their parents/legal guardians were recruited. The children's myopia ranged from -0.50 to -5.00 diopters (D), and their astigmatism was <1.50 D. They had all been wearing OK contact lenses or SVS for at least 12 months. The children completed the Child PedEyeQ. One of their parents (or a legal guardian) completed the Proxy PedEyeQ and the Parent PedEyeQ. Rasch-calibrated PedEyeQ scores were calculated for each domain and were converted to a scale from 0 to 100 for statistical analysis.

Results

A total of 50 children wearing OK contact lenses, 43 children wearing SVS, and their parents/legal guardians completed the questionnaires. The scores of all Child, Proxy, and Parent PedEyeQ domains in the OK contact lens group were higher than those in the SVS group (all P < 0.05). In the mild and moderate myopia subgroups, the Child, Proxy, and Parent PedEyeQ scores in the mild myopia OK contact lens subgroup were higher than those in the mild myopia SVS group (all P < 0.05) except functional vision and bothered by eyes/vision domains for the proxy PedEyeQ. Similarly, the Child, Proxy, and Parent PedEyeQ scores in the moderate myopia OK contact lens subgroup were higher than those in the moderate myopia SVS subgroup (all P < 0.05) except impact on parent and family domain for the parent PedEyeQ. In the subgroup analysis of glasses type, no significant score difference of any Child, Proxy, and Parent PedEyeQ domain was detected between mild and moderate myopia in either the OK contact lens group or the SVS group (all P > 0.05).

Conclusion

Compared with children wearing SVS, children wearing OK contact lenses have better functional vision and eye-related quality of life. Moreover, OK contact lens has a better correction effect, higher acceptance rates, and less impact on parents and families than SVS.

Refractive Management of Surgical-Induced Presbyopia in a Young Patient with Vision-Related Quality of Life Complaints: A Case Report

Visual difficulties can negatively impact life quality. Our purpose was to report the refractive surgical planning and outcomes of a young patient with mixed astigmatism and phacoemulsification-induced presbyopia due to congenital cataracts who was unsatisfied with her vision-related quality of life. A 32-year-old woman, submitted to phacoemulsification with implantation of a monofocal intraocular lens (IOL) and Nd:YAG laser posterior capsulotomy 3 years before, due to congenital cataracts, was referred to the Refractive Surgery Unit of Centro Hospitalar Universitário de Santo António. She had mixed astigmatism (+1.00-4.00 × 10° in the right eye [RE] and +0.50-1.75 × 180° in the left eye [LE]) and surgical-induced presbyopia, was intolerant to contact lenses, and felt that her vision significantly impaired her life quality. A trifocal Sulcoflex® (Rayner) IOL was implanted to correct the spherical and near refractive errors. In a second surgical time, a photorefractive keratectomy was performed to correct the residual astigmatism (-3.50 × 10° in the RE and -1.50 × 170° in the LE). In the last visit, distance and near uncorrected visual acuity were 20/20 (Snellen) and Jaeger 1, respectively, in both eyes, and the patient was very satisfied. When assessing the surgical options of young, working-age patients, clinicians should, when possible, consider alternative solutions to monofocal IOLs. In this patient, the combination of corneal and intraocular procedures allowed the correction of both the distance and near refractive errors, with a subsequent significant improvement in the patient's quality of life.

Vision Quality Questionnaire Assessment in Patients After Topography-Guided Photorefractive Keratectomy for Irregular Astigmatism Secondary to Radial Keratotomy

Aim

To evaluate the vision-related quality of life with the National Eye Institute Refractive Error Quality of Life (NEI-RQL) questionnaire in patients with astigmatism secondary to radial keratotomy surgery who underwent topography-guided photorefractive keratectomy.

Methods

Prospective non-randomized clinical trial. This study included 15 patients (30 eyes) aged > 21 years, mean age 55.1 (SD, 3.5) years, 53.3% female, with astigmatism ≤ - 6.00 D resulting from radial keratotomy, which could have been associated with hyperopia ≤ + 6.00 D. Photorefractive keratectomy with topography-guided custom ablation treatment was used in all cases. The patients answered the NEI-RQL questionnaire preoperatively and at 4 and 48 months after topography-guided photorefractive keratectomy. The following data were collected: age, sex and education level, pre-operative refraction data, visual acuity with or without correction, pachymetry, and keratometry.

Results

There was a significant difference between pre-and postoperative NEI-RQL scores for the domains clarity of vision, near vision, far vision, diurnal fluctuation, activity limitations, glare, symptoms, correction dependence, appearance, and satisfaction with correction (p < 0.001).

Conclusion

Topography-guided photorefractive keratectomy improved vision-related quality of life in patients with a history of irregular astigmatism secondary to radial keratotomy.

Visual outcomes and quality of life before and after photorefractive keratectomy

Purpose

To compare visual outcomes and vision-related quality of life (VRQoL) between subjects before and after photorefractive keratotomy (PRK) and controls. In addition, VRQoL was compared between subjects at different periods of PRK surgery.

Methods

This was a cross-sectional study that included subjects with refractive errors aged 19-40 years and age-matched controls. Subjects were divided into three groups: pre-, post-PRK, and control. Subjects in the post-PRK group were divided into three subgroups (1-week, <6-month, and >6-month follow-up visits). Measurements including uncorrected distance visual acuity (UCVA), corrected distance visual acuity (CDVA), spherical equivalent (SE) of manifest refraction, and corneal topography were obtained for all participants. The Quality of Life Impact of Refractive Correction (QIRC) questionnaire was administered to compare VRQOL between groups and between post-refractive surgery subgroups.

Results

A total of 145 participants were included in this study. The mean age ± standard deviation (SD) of all participants was 26.29 ± 5.1 years. There was a significant difference (P < 0.001) in total QIRC scores between groups. The total QIRC score was better in the post-PRK group than in the pre-PRK and control groups. The scores of items included in the convenience, well-being, and health concern domains were significantly higher in the post-PRK group than in the pre-PRK and control groups. Within the post-PRK group, significant differences (P < 0.001) were found in UCVA and SE between the post-PRK subgroups. Uncorrected VA and SE were better in the post-PRK groups who were followed up in the < 6 and > 6 months subgroups than in the 1-week follow-up subgroup (P < 0.0001).

Conclusion

A significant improvement in visual outcomes and VRQoL occurred after PRK surgery. Subjects enjoyed their VRQoL after refractive surgery.

Development of the Near Vision Presbyopia Task-based Questionnaire for use in evaluating the impact of presbyopia

Background

Presbyopia is a progressive condition that reduces the eye’s ability to focus on near objects with increasing age. After a systematic literature review identified no existing presbyopia-specific patient-reported outcome (PRO) instruments meeting regulatory guidance, a new PRO instrument, the Near Vision Presbyopia Task-based Questionnaire (NVPTQ), was developed.

Results

To explore the patient experience with presbyopia, concept elicitation interviews were conducted with 20 presbyopic participants. The most frequently reported impacts were difficulty with reading menus/books/newspapers/magazines, reading on a cell phone/caller ID, and reading small print. Based on these results, a task-based PRO instrument (the NVPTQ) was developed instructing participants to complete four near-vision, paper-based reading tasks (book, newspaper, nutrition label, menu) under standardized settings, and subsequently assess their vision-related reading ability and associated satisfaction. The draft NVPTQ was cognitively debriefed with a sample of 20 presbyopes, which demonstrated that most participants interpreted the items as intended and endorsed the relevance of the concepts being assessed. After the qualitative research, the draft instrument was psychometrically tested using data from a Phase 2 study. Based on item-level analyses, all items in the NVPTQ demonstrated expected response option patterns and lacked substantial floor or ceiling effects. The reliability, validity, and responsiveness of the NVPTQ Performance and Satisfaction domain scores were assessed. All domains scores had large Cronbach’s coefficient α values and good test–retest statistics, indicating that the scores are internally consistent and produce stable values over time. The pattern of correlations with a concurrent measure of visual functioning (National Eye Institute Visual Function Questionnaire 25) demonstrated that the NVPTQ domain scores were related to an alternative assessment of near-vision activities. The NVPTQ domain scores were able to distinguish between groups that were known to differ on the clinical outcome of uncorrected near visual acuity, supporting the construct validity of these scores. The NVPTQ domain scores showed evidence of responsiveness to change by being able to distinguish between groups defined as improved and not improved based on patient-reported and clinical outcomes.

Conclusions

This research has resulted in a content-valid and psychometrically sound instrument designed to evaluate vision-related reading ability and satisfaction with vision-related reading ability.

Trial registration: ClinicalTrials.gov NCT02780115. Registered 23 May 2016, https://www.clinicaltrials.gov/ct2/show/NCT02780115?term=NCT02780115&draw=2&rank=1.

IMI Impact of Myopia

The global burden of myopia is growing. Myopia affected nearly 30% of the world population in 2020 and this number is expected to rise to 50% by 2050. This review aims to analyze the impact of myopia on individuals and society; summarizing the evidence for recent research on the prevalence of myopia and high myopia, lifetime pathological manifestations of myopia, direct health expenditure, and indirect costs such as lost productivity and reduced quality of life (QOL). The principal trends are a rising prevalence of myopia and high myopia, with a disproportionately greater increase in the prevalence of high myopia. This forecasts a future increase in vision loss due to uncorrected myopia as well as high myopia-related complications such as myopic macular degeneration. QOL is affected for those with uncorrected myopia, high myopia, or complications of high myopia. Overall the current global cost estimates related to direct health expenditure and lost productivity are in the billions. Health expenditure is greater in adults, reflecting the added costs due to myopia-related complications. Unless the current trajectory for the rising prevalence of myopia and high myopia change, the costs will continue to grow. The past few decades have seen the emergence of several novel approaches to prevent and slow myopia. Further work is needed to understand the life-long impact of myopia on an individual and the cost-effectiveness of the various novel approaches in reducing the burden.

Bilateral Ultrathin Descemet's Stripping Automated Endothelial Keratoplasty vs. Bilateral Penetrating Keratoplasty in Fuchs' Dystrophy: Corneal Higher-Order Aberrations, Contrast Sensitivity and Quality of Life

Background and Objectives: The objective of this paper is to compare the visual outcomes and quality of life (QoL) after bilateral ultrathin Descemet's stripping automated endothelial keratoplasty (UT-DSAEK) with bilateral penetrating keratoplasty (PK) for Fuchs' endothelial dystrophy (FED). Materials and Methods: Retrospective comparative cohort study, including 11 patients with FED who underwent bilateral PK and 13 patients with FED who underwent bilateral UT-DSAEK. All patients were already pseudophakic or had undergone a combined cataract procedure. The main outcomes were corrected distance visual acuity (CDVA) corneal higher-order aberrations (HOAs), contrast sensitivity (CS) and quality of life (QoL). Results: The mean follow-up after the second eye surgery was 32.5 ± 10.2 months in PK and 19.6 ± 8.6 months in UT-DSAEK patients. The CDVA in the UT-DSAEK group was significantly better than in the PK one (0.18 ± 0.07 vs. 0.35 ± 0.16 logMAR, p < 0.0001). The mean anterior corneal total HOAs of the central 5 mm were significantly lower in UT-DSAEK eyes than in PK eyes (0.438 ± 0.078 µ and 1.282 ± 0.330 µ respectively, p < 0.0001), whilst the mean posterior total HOAs did not differ between groups (0.196 ± 0.056 µ and 0.231 ± 0.089 µ, respectively, p = 0.253). The CS was lower at 0.75 and 1.5 cycles/degree in P the K group when compared to the DSAEK one (p = 0.008 and 0.005, respectively). The QoL scores by the NEI RQL-42 test exhibited better values in DSAEK patients in 9 out of 13 scales. Conclusion: Our study confirms that UT-DSAEK provides a better visual function in terms of CDVA and CS, together with lower HOAs, when compared to PK. Hence, the vision-related QoL, binocularly evaluated by the NEI RQL-42 items, indicates a higher satisfaction in UT-DSAEK eyes.

Comparing Patient-Reported Outcomes of Laser In Situ Keratomileusis and Small-Incision Lenticule Extraction: A Review

PURPOSE

Laser in situ keratomileusis (LASIK) and small-incision lenticule extraction (SMILE) are popular refractive surgeries. The objective refractive outcomes of LASIK and SMILE have been studied extensively; both procedures have comparable safety, efficacy, and predictability. However, owing to various psychosocial factors, refractive patients may report dissatisfaction despite good postoperative vision. Hence the importance of studies on subjective patient-reported outcomes. This review discusses the role of psychometric-technique-based validated questionnaires when evaluating subjective outcomes. It also summarizes the literature on patient-reported outcomes for LASIK and SMILE.

DESIGN

A literature search was performed on PubMed database to identify studies that have assessed patient-reported outcomes for LASIK and SMILE.

RESULTS

Several studies have looked into patient-reported outcome measures for LASIK, but the number of equivalent studies for SMILE is limited. Questionnaires (validated and non-validated) are used to evaluate patient-reported outcomes. Validated questionnaires are designed based on psychometric techniques, such as Classic Test Theory, Item Response Theory, and Rasch analysis. The Quality of Life Impact of Refractive Correction (QIRC) questionnaire, a validated questionnaire administered to both LASIK and SMILE patients, suggests that both groups have comparable vision-related quality of life in the first few months postoperatively; but SMILE might confer a slight advantage in the later postoperative period (postoperative month 6).

CONCLUSIONS

Future LASIK-SMILE comparative studies utilizing standardized validated questionnaires for patient-reported outcome measures with longer follow-up durations would be a welcome contribution to this important aspect of refractive surgery.

Vision-Specific Quality of Life: Laser-Assisted in situ Keratomileusis Versus Overnight Contact Lens Wear

OBJECTIVES

To compare the visual-related quality of life in myopic subjects with different refractive treatments such as continuous wear of silicone-hydrogel contact lenses (CL), corneal refractive therapy (CRT), and laser-assisted in situ keratomileusis (LASIK).

METHODS

The National Eye Institute Refractive Error Quality of Life Instrument (NEI RQL-42) questionnaire was administered to 96 subjects with a mean age of 30.0±7.9 years. There were 72 myopic subjects with a mean spherical equivalent of -2.74±0.98 D (-5.50 to -1.25 D). Subjects were corrected with LASIK (n=24), Paragon CRT orthokeratology lenses (n=24), and lotrafilcon A silicone-hydrogel CL under continuous wear (n=24). The NEI RQL-42 survey was used to compare differences between groups as well as with an emmetropic group (n=24).

RESULTS

After 1 year of treatment, significant differences were found among all groups in the subscales glare (P=0.017), symptoms (P=0.016), dependence on correction (P<0.001), and worry (P<0.001). The mean difference compared with emmetropes were -5.5% (P=0.063) for LASIK patients, -2.0% (P=0.212) for orthokeratology subjects, and +1.6% (P=0.934) for the silicone-hydrogel CL group.

CONCLUSIONS

Myopic subjects analyzed in this study reported better vision-related quality of life when they were corrected with continuous wear silicone-hydrogel lenses. The average score reached by CRT was similar to emmetropes, which showed the main disadvantage in worry subscale. The patients who underwent LASIK had the lowest valuation, highlighting the decreases in scores of diurnal fluctuations, glare, and especially in expectations and worry subscales, due to the first and second subscales, but especially to the false expectations created about treatment.

Initial Single-Site Surgical Experience with SMILE: A Comparison of Results to FDA SMILE, and the Earliest and Latest Generation of LASIK

Introduction

The primary objective was to show our initial surgical single-site experience with small incision lenticule extraction (SMILE) after the official enrollment in March 2017 following Food and Drug Administration (FDA) approval for simple myopia in late 2016 in the United States and, subsequently, compare our results to the earliest and most advanced generation of excimer platforms for laser-assisted in situ keratomileusis (LASIK) surgery.

Methods

This was a retrospective single-site study of 68 eyes from 35 patients who had SMILE surgery. The patients’ preoperative and postoperative uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest sphere, manifest cylinder, intraoperative complications, and preoperative and postoperative visual symptoms were collected. We compared our findings to the results from the FDA SMILE study, and to the three earliest (1999–2000) and three of the most updated (2013–2016) platforms for LASIK.

Results

The cumulative UDVA was 20/20 and 20/40 or better in 74% and 100% of patients, respectively. The intended target refraction was within ± 0.5 and ± 1.00 D in 80% and 93% of cases, respectively. The prevalence of dry eyes decreased by nearly half from 1-week to the 6-month postoperative interval. Patients noted improvement in glare (17%), halos (17%), fluctuation (25%), and depth perception (8%) at the 6-month interval compared to preoperative levels.

Conclusions

This study’s findings are consistent with current SMILE reports. Notably, the results are superior to the earliest generation of LASIK, however inferior to the latest excimer platforms. SMILE does meet the efficacy and safety criteria met by FDA; however, there is a definite need for further improvement to reach the superior refractive outcomes produced by the latest generation of LASIK platforms.

Patient-reported Outcomes for Assessment of Quality of Life in Refractive Error: A Systematic Review

SIGNIFICANCE

This review has identified the best existing patient-reported outcome (PRO) instruments in refractive error. The article highlights the limitations of the existing instruments and discusses the way forward.

PURPOSE

A systematic review was conducted to identify the types of PROs used in refractive error, to determine the quality of the existing PRO instruments in terms of their psychometric properties, and to determine the limitations in the content of the existing PRO instruments.

METHODS

Articles describing a PRO instrument measuring 1 or more domains of quality of life in people with refractive error were identified by electronic searches on the MEDLINE, PubMed, Scopus, Web of Science, and Cochrane databases. The information on content development, psychometric properties, validity, reliability, and responsiveness of those PRO instruments was extracted from the selected articles. The analysis was done based on a comprehensive set of assessment criteria.

RESULTS

One hundred forty-eight articles describing 47 PRO instruments in refractive error were included in the review. Most of the articles (99 [66.9%]) used refractive error-specific PRO instruments. The PRO instruments comprised 19 refractive, 12 vision but nonrefractive, and 16 generic PRO instruments. Only 17 PRO instruments were validated in refractive error populations; six of them were developed using Rasch analysis. None of the PRO instruments has items across all domains of quality of life. The Quality of Life Impact of Refractive Correction, the Quality of Vision, and the Contact Lens Impact on Quality of Life have comparatively better quality with some limitations, compared with the other PRO instruments.

CONCLUSIONS

This review describes the PRO instruments and informs the choice of an appropriate measure in refractive error. We identified need of a comprehensive and scientifically robust refractive error-specific PRO instrument. Item banking and computer-adaptive testing system can be the way to provide such an instrument.

Impact of refractive error on quality of life: a qualitative study

IMPORTANCE

This study qualitatively explores the impact of refractive error on adults, particularly after correction.

BACKGROUND

The study aimed to explore the impact of refractive error on quality of life.

DESIGN

Cross-sectional; in-depth telephone and face-to-face semistructured interviews; qualitative study with inductive and deductive processes.

PARTICIPANTS

Forty-eight adults with refractive error (including presbyopia) were recruited from the Flinders Vision, the Ashford Advanced Eye Care and among Flinders University staff and students, in South Australia.

METHODS

The interviews were audio-recorded, transcribed verbatim, coded and analysed using thematic analysis.

MAIN OUTCOME MEASURES

Themes and categories RESULTS: The median age of the participants was 49 years (min: 22 years; max: 76 years). Most of them were female: (29; 59%). Most of them (36; 75.0%) had myopia followed by hyperopia (12; 25.0%). Twenty-two (45.8%) participants had astigmatism. Similarly, 23 (47.9%) of them were presbyopes. Most of the participants (39; 81.3%) wore glasses; 17 (35.4%) used contact lenses, and 17 (35.4%) had undergone refractive surgery. A total of 2367 comments were coded. Thematic analysis resulted into six themes that informed about quality of life issues in people with refractive error. Concerns about cosmetic appearance, personal health and safety, difficulties in day-to-day activities and inconveniences rendered in daily life were identified as the most important themes.

CONCLUSIONS AND RELEVANCE

The findings of this study enrich the understanding on the issues important in people with refractive error. The quality of life issues identified will be used to develop a refractive error-specific item bank.

Reading and Quality of Life Differences between Tecnis ZCB00 Monofocal and Tecnis ZMB00 Multifocal Intraocular Lenses

Purpose

To compare the NEI-RQL-42 quality of life questionnaire and the Radner Vissum reading test outcomes after bilateral cataract surgery with implantation of Tecnis ZCB00 monofocal and Tecnis ZMB00 multifocal intraocular lens (IOL).

Methods

Forty-two eyes of 21 patients who had phacoemulsification were implanted with Tecnis ZCB00 IOL and 82 eyes of 41 patients were implanted with Tecnis ZMB00 IOL. They answered the NEI-RQL-42 questionnaire before cataract surgery and 3 months after it. The Radner Vissum test was performed 3 months after the surgery with optical correction for near vision in patients with monofocal IOL, but without it in patients with multifocal IOL.

Results

Regarding the NEI-RQL-42 test, the multifocal group obtained better results in items 2, 7, 8, 11, 13, 31, and 40, and in the following categories: near vision, dependence on correction, and suboptimal correction (p<0.05). The monofocal group only showed better results in item 17. As for the Radner Vissum test, the multifocal group obtained significantly better results in phrases 1, 3, 4, and 5, and in the number of incorrect syllables (p<0.05).

Conclusions

Patients with Tecnis ZMB00 multifocal IOL report a higher quality of life regarding the lack of need for optical correction for near vision in their daily activities, but halos in vision at night. Additionally, patients with multifocal IOL achieve similar or better reading quality at near vision and under photopic lighting conditions than patients with monofocal IOL with near vision optical correction.

Assessment of subjective intraocular forward scattering and quality of vision after posterior chamber phakic intraocular lens with a central hole (Hole ICL) implantation

PURPOSE

To evaluate the subjective intraocular forward scattering and quality of vision after posterior chamber phakic intraocular lens with a central hole (Hole ICL, STAAR Surgical) implantation.

METHODS

We prospectively examined 29 eyes of 29 consecutive patients (15 men and 14 women; ages, 37.2 ± 8.8 years) undergoing Hole ICL implantation. We assessed the values of the logarithmic straylight value [log (s)] using a straylight meter (C-Quant^™ , Oculus) preoperatively and 3 months postoperatively. The patients completed a questionnaire detailing symptoms on a quantitative grading scale (National Eye Institute Refractive Error Quality of Life Instrument-42; NEI RQL-42) 3 months postoperatively. We compared the preoperative and postoperative values of the log(s) and evaluated the correlation of these values with patient subjective symptoms.

RESULTS

The mean log(s) was not significantly changed, from 1.07 ± 0.20 preoperatively, to 1.06 ± 0.17 postoperatively (Wilcoxon signed-rank test, p = 0.641). There was a significant correlation between the preoperative and postoperative log(s) (Spearman's correlation coefficient r = 0.695, p < 0.001). The postoperative log(s) was significantly associated with the scores of glare in the questionnaire (Spearman's correlation coefficient r = -0.575, p = 0.017).

CONCLUSIONS

According to our experience, Hole ICL implantation does not induce a significant additional change in the subjective intraocular forward scattering. The symptom of glare after Hole ICL implantation was significantly correlated with the postoperative intraocular forward scattering in relation to the preoperative one.

[Evaluation of vision quality after laser vision correction in healthcare professionals]

PURPOSE

Healthcare professionals require good quality of vision. The main objective of this study is to evaluate the satisfaction and vision quality after laser vision correction in healthcare professionals.

METHODS

This is a monocentric retrospective study. An online 25-question survey was sent to ametropic physicians, surgeons and nurses who underwent corneal refractive surgery with laser-assisted in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK) between July 2012 and February 2016. Questionnaire responses were recorded anonymously by the internet survey site. These patients' pre- and postoperative data were analyzed.

RESULTS

In total, 2491 laser vision corrections were performed during this time frame. One hundred and fifty-eight patients were healthcare providers; 131 received the survey, and 111 responded. Ninety-nine were surgeons, 60 were medical physicians, and 32 were nurses. Ninety-one percent reported that they were satisfied with their postoperative vision quality, 63.9% even reported an improvement in their quality of vision compared with their corrected preoperative vision, 92.8% reported that they would have the procedure again, and 94.6% would recommend the procedure to a family member or a patient. Visual outcomes showed high levels of efficacy and predictability.

CONCLUSION

While healthcare professionals require good quality of vision, those who had undergone laser vision correction reported the same satisfaction as the general population and would recommend the procedure to their family, friends and patients.

Comparison of quality of life between myopic patients with spectacles and contact lenses, and patients who have undergone refractive surgery

Purpose

The present study aims at investigating and comparing the vision-related quality of life of myopic persons who wear spectacles or contact lenses with those who have undergone refractive surgery. It also compares the vision-related quality of life of these two groups with that of emmetropes.

Method

In this study, the questionnaire of evaluation instrument of refractive error in quality of life (NEI/RQL-42) was used to compare the quality of life between 154 myopic patients with spectacles and contact lenses, and 32 patients who have undergone refractive surgery. The two groups were also compared with 54 emmetropes. The questionnaire included 13 different subgroups (score 0–100) related to vision. Data was analyzed using SPSS software.

Results

The overall score of quality of life in emmetropes (95.11 ± 4.23) was more than that in persons who had undergone refractive surgery (86.98 ± 4.73), and it was the least in the group wearing spectacles or contact lenses (78.30 ± 9.21), (P < 0/001). Furthermore, except for a glare variable, the studied groups indicated a statistically significant difference in all the thirteen subgroups of vision-related quality of life.

Conclusion

Quality of life for people with myopia who had the refractive surgery was better than people with myopia who wore spectacles or contact lenses. Although quality of life in people with myopia who had the refractive surgery was less than emmetropia, it seems that refractive surgery improves quality of life of myopic patients.

IURead: a new computer-based reading test

PURPOSE

To develop a computer-based single sentence reading test especially designed for clinical research enabling multiple repeat trials without reusing the same sentences.

METHODS

We initially developed 422 sentences, with an average of 60 characters and 12 words. Presentation controls were improved by employing computer-based testing and the oral reading was recorded by visual inspection of digital audio recordings. Variability in reading speed of normally sighted adults between sentences, between charts, between subjects, between formats, and between display devices was quantified. The impact of display size and pixel resolution on test geometry was assessed, and the impact of reduced retinal image quality and retinal illuminance were compared for reading and standard letter acuities. Eleven visually normal subjects (age: 18-60 years) participated in this study.

RESULTS

Stopwatch timing of sentences reliably underestimated reading times by about 0.3 s, and exhibited coefficients of repeatability 17 times larger than those estimated from visual inspection of digital recordings. A slight relaxing of the lexical content constraints had no effect on reading speed; neither did sentence format (single vs three lines) or display size or distance. Within subject standard deviations of reading speed for different sentences were small (between 6% and 9% of the mean speed) requiring only small samples sizes to achieve typical statistical reliability and power when comparing conditions within individual subjects. The greater variability associated with stopwatch timing necessitates larger sample sizes. As defocus and light level were varied, reading acuity and standard letter acuity were highly correlated (r(2)  = 0.99), and reading acuity was slightly better.

DISCUSSION

A computer-based IURead reading test provides a useful reading speed and reading acuity tool for clinical research involving multiple conditions and repeat testing of individual subjects. Ready to use IURead files for use with a computer, tablet or cell phone can be downloaded from our lab website (https://www.opt.indiana.edu/Bradley/Downloads.aspx).

Indications for and outcomes of tertiary referrals in refractive surgery

PURPOSE

To review the spectrum of disease, symptomatology, and management offered to patients referred for a second opinion after refractive surgery.

METHODS

A prospective cohort study was done on all patients referred from October 1, 2006, to September 30, 2011, to a tertiary eye clinic after refractive surgery of any kind (ie, corneal laser surgery, conductive keratoplasty, radial keratotomy, phakic implants, refractive lens exchanges, or any combination thereof). Data analysis was performed on all demographic and clinical aspects of this cohort, including the initial complaint, type of referral, number of complaints, procedure previously performed, diagnosis at our center, type of advice given, and rate and type of surgical intervention.

RESULTS

One hundred thirty-one eyes (69 patients) were included. Corneal refractive surgery was performed in 82% (108 eyes), and 11% (14 eyes) were seen after phakic intraocular lens (PIOL) implantation and 7% (9 eyes) after refractive lens exchange. The most common diagnoses were tear film dysfunction (30 eyes, 23%), residual refractive error (25 eyes, 19%), and cataract (20 eyes, 15%). Most patients (42 patients, 61%) were treated conservatively. In 27 patients (39%), 36 eyes (28%) were managed surgically. Severe visual loss was seen in 1 eye.

CONCLUSIONS

No major problems were found in most second opinions after refractive surgery referral. Dry eyes, small residual refractive error, or higher-order aberrations were the most common complaints. Surgical intervention was needed in 36 eyes (28%), almost half of which were cataract extractions. Severe visual loss was seen in 1 eye with a PIOL. There was no incidence of severe visual loss in keratorefractive and refractive lens exchange procedures.

Psychometric properties of the national eye institute refractive error correction quality-of-life questionnaire among Iranian patients

BACKGROUND AND AIM

To evaluate the psychometric properties of the national Eye Institute refractive error correction quality of life questionnaire (NEI-RQL-42) among Iranian patients with refractive errors.

MATERIALS AND METHODS

Two samples of patients (n1 = 296, n2 = 95) were consecutively selected from the eye clinic of the Boo-Ali Hospital, Qazvin. A forward-backward procedure was conducted to translate and cross-culturally adapt the Iranian version of the NEI-RQL-42. A homogeneity, stability, and reliability test was conducted for the first sample after a two-week interval. Convergent validity was computed using the correlation between the NEI-RQL-42 subscale scores, National Eye Institute-Visual Functioning Questionnaire (NEI-VFQ-25), and the Short Form-36 (SF-36). Furthermore, Known-group analysis was performed, to determine the discriminant validity between the subgroups of patients with hyperopia, emmetropia, and myopia. Responsiveness to clinical change was tested by administering NEI-RQL-42 on the second sample that was scheduled for surgery.

RESULTS

Homogeneity was satisfactory with the Cronbach's alpha coefficients ranging between 0.70 and 0.92. The 13 subscales of the NEI-RQL-42 showed a considerable stability in intra-class-correlation (ICC) ranging between 0.70 and 0.89. Positive correlation coefficients were found among all subscales of the NEI-RQL-42 and the other quality-of-life instruments (NEI-VFQ-25 and SF-36). The NEI-VFQ-25 displayed excellent discriminant validity to differentiate the subgroups of patients, and was found to be responsive to change after the surgical correction at three months.

CONCLUSIONS

The Iranian version of the NEI-RQL-42 is a valid and reliable instrument to assess refractive error correction quality-of-life in Iranian patients. Moreover this questionnaire can be used to evaluate the effectiveness of interventions in patients with refractive errors.

Clinical evaluation of two multifocal intraocular lens implantation patterns

AIM

To evaluate the visual outcomes and patient satisfaction of two multifocal intraocular lens implantation patterns, with the decision between the two patterns being guided by the patients' choice of visual zones that best suited their lifestyle, or lifestyle zones.

METHODS

This is a prospective non-randomized comparative study. The lifestyle zones of 32 consecutive age-related cataract patients (64 eyes) were investigated individually to guide the surgical decision between two multifocal intraocular lens implantation patterns. The first group (MIX) received a combined implantation of a ReZoom NXG1 lens in the dominant eye and a Tecnis ZM900 lens in the other eye. The second group (MATCH) received bilateral ReZoom NXG1 lenses. One year postoperatively, the patients were assessed for binocular uncorrected visual acuity, reading visual acuity, reading speed and depth of focus under different luminance and were surveyed for visual disturbances, satisfaction and complete spectacle independence.

RESULTS

According to the determination of lifestyle zones, 18 and 14 patients were included in the MIX and MATCH groups, respectively. One year postoperatively, each of the patients exhibited positive visual outcomes and lifestyle satisfaction, although there were still some differences between the two groups. Generally, patients in the MATCH group had better distance visual acuity than those in the MIX group. In contrast, patients in the MIX group had better near visual acuity, better reading acuity and better reading speed than those in the MATCH group. Between the two groups, there was no clear difference in intermediate visual acuity, and the depths of focus between the two groups were approximately equal. The results of the mean NEI-RQL-42 questionnaire score, overall satisfaction, and complete spectacle independence did not differ between the two groups.

CONCLUSION

Different multifocal intraocular lenses implantation patterns can have differing advantages and disadvantages; however, the best results with respect to visual outcome and patient satisfaction can be achieved by taking individual lifestyle zones into account.

Agreement about identifying patients who change over time: cautionary results in cataract and heart failure patients

BACKGROUND

Preference-based measures of health-related quality of life all use the same dead = 0.00 to perfect health = 1.00 scale, but there are substantial differences among measures.

OBJECTIVE

The objective was to examine agreement in classifying patients as better, stable, or worse.

METHODS

The EQ-5D, Health Utilities Index Mark 2 and Mark 3, Quality of Well-Being-Self-Administered scale, Short-Form 36 (Short-Form 6D), and disease-targeted measures were administered prospectively in 2 clinical cohorts. The study was conducted at academic medical centers: University of California, Los Angeles; University of California, San Diego; University of Wisconsin-Madison; and University of Southern California. Patients undergoing cataract extraction surgery with lens replacement completed the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25). Patients newly referred to congestive heart failure specialty clinics completed the Minnesota Living with Heart Failure Questionnaire (MLHF). In both cohorts, subjects completed surveys at baseline and at 1 and 6 months. The NEI-VFQ-25 and MLHF were used as gold standards to assign patients to categories of change. Agreement was assessed using κ.

RESULTS

There were 376 cataract patients recruited. Complete data for baseline and the 1-month follow-up were available on all measures for 210 cases. Using criteria specified by Altman, agreement was poor for 6 of 9 pairs of comparisons and fair for 3 pairs. There were 160 heart failure patients recruited. Complete data for baseline and the 6-month follow-up were available for 86 cases. Agreement was negligible for 5 pairs and fair for 1. The study was conducted on selected patients at a few academic medical centers.

CONCLUSIONS

The results underscore the lack of interchangeability among different preference-based measures.

Reading ability and stereoacuity with combined implantation of refractive and diffractive multifocal intraocular lenses

PURPOSE

To evaluate reading ability and stereoscopic vision with combined implantation of refractive and diffractive multifocal intraocular lenses (IOLs).

METHODS

Thirty-one cataract patients (62 eyes) were assigned to receive either a ReZoom NXG1 IOL in the dominant eye and a Tecnis ZM900 IOL in the fellow eye (MIOL group), or Sensar AR40e IOLs bilaterally (SIOL group). The uncorrected visual acuity (UCVA) at 500 cm, best spectacle-corrected visual acuity (BSCVA) at 500 cm, reading acuity, reading speed, near stereoacuity and questionnaire were assessed 3 months postoperatively.

RESULTS

Three months postoperatively, monocular and binocular UCVA and BSCVA at 500 cm showed no significant differences in both groups. The uncorrected reading acuity and reading speed in the MIOL group were significantly better than those in the SIOL group and were similar to that with correction in the SIOL group. The uncorrected mean near stereoacuity in the MIOL group was significantly better than that in the SIOL group (69 ± 50 seconds of arc in the MIOL group versus 180 ± 160 seconds of arc in the SIOL group). Patients in the MIOL group had a high level of satisfaction and more than 80% of them had an increased independence from spectacles for brief reading.

CONCLUSION

The combined implantation of refractive and diffractive multifocal IOLs was effective in improving reading ability and near stereoacuity with a good visual quality.

Psychometric properties of the Greek NEI-RQL-42

Purpose

To evaluate the psychometric properties of the Greek National Eye Institute Refractive Error Quality of Life Questionnaire (NEI-RQL-42).

Methods

We developed the Greek version of the instrument using forward and backward translation. To examine reliability, Cronbach alpha for each subscale was used as an index of internal consistency. Test-retest reliability was evaluated with intraclass correlation coefficients (ICC). Regarding construct validity, both convergent and discriminant validities were calculated by means of multi-trait analysis. Furthermore, the instrument was evaluated by Rasch analysis, as well.

Results

Three patient groups were studied (emmetropes (n=20), myopes (n=41), and hyperopes (n=18)). Emmetropes scored significantly better in the majority of subscales, while myopes scored better than hyperopes in clarity of vision (p=0.012), near vision (p<0.001), and satisfaction with correction (p=0.001). Cronbach alpha ranged from 0.490 (glare) to 0.948 (expectations), with most subscales having high internal consistency. The ICCs ranged from 0.76 to 0.93 for all subscales. All items passed the convergent and discriminant validity tests. Strong correlations were detected between uncorrected visual acuity and near vision, expectations, activity limitations, dependence on correction, worry, and suboptimal correction subscales. Rasch analysis revealed potential weaknesses of the instrument that are associated with the assumptions of the model itself. Specifically, 3 items and 17.5% of the participants fell outside the tolerance box. Moreover, principal component analysis indicated average unidimensionality for the instrument.

Conclusions

Traditional validation methods indicate that the Greek NEI-RQL-42 scale has adequate psychometric properties for comparative studies in local populations. Rasch analysis indicates significant misfits to the model that should be taken into consideration and evaluated in future studies. These misfits might reflect inherent weaknesses of the original NEI-RQL-42 and not of its adaptation to Greek norms.

Comparison of outcomes with multifocal intraocular lenses: a meta-analysis

Purpose

To compare the clinical outcome of different multifocal intraocular lenses (IOLs) based on information reported in the international literature.

Methods

All comparative clinical trials that involved implanting at least one multifocal IOL in patients with cataract or presbyopia were extracted from the literature. Clinical outcomes included uncorrected near visual acuity, uncorrected distance visual acuity, visual acuity, spectacle independence, and halos. Random effects meta-analyses were conducted to compare outcomes for the different IOL types.

Results

Twenty papers were identified describing 11 monofocal IOLs and 35 multifocal IOLs (19 diffractive, including 12 ReSTOR^®, 14 refractive, and two accommodative) patient cohorts. Multifocal and monofocal uncorrected distance visual acuity was 0.165 (0.090–0.240) and 0.093 (0.088–0.098), respectively. Compared with monofocal IOLs, multifocal IOLs produced better uncorrected near visual acuity (0.470 [0.322–0.618] versus 0.141 [0.131–0.152]; P < 0.0001), resulting in higher spectacle independence (incidence rate ratio [IRR] 3.62 [2.90–4.52]; P < 0.0001). Compared with refractive multifocal IOLs, diffractive multifocal IOLs produced a similar uncorrected distance visual acuity (0.105 [0.098–0.111] versus 0.085 [0.029–0.140]; P ≤ 0.78, not significant) and better uncorrected near visual acuity (0.217 [0.118–0.317] versus 0.082 [0.067–0.098]; P < 0.0001) resulting in higher spectacle independence (IRR 1.75 [1.24–2.48]; P < 0.001). Compared with other multifocal IOLs, ReSTOR produced a better uncorrected distance visual acuity (0.067 [0.059–0.076] versus 0.093 [0.088–0.098]; P < 0.0001) and better uncorrected near visual acuity (0.064 [0.046–0.082] versus 0.141 [0.131–0.152]; P < 0.006), resulting in higher spectacle independence (IRR 2.06 [1.26–1.36]; P < 0.004). Halo incidence rates with different types of multifocal implants did not differ significantly.

Conclusion

Multifocal IOLs provide better uncorrected near visual acuity than monofocal IOLs, leading to less need for spectacles. Multifocal IOL design might play a role in postsurgical outcome, because better results were obtained with diffractive lenses. ReSTOR showed better uncorrected near visual acuity, uncorrected distance visual acuity, and higher spectacle independence rates compared with other multifocal IOLs.

The Refractive Status and Vision Profile (RSVP): Translation Into Persian, Reliability and Validity

PURPOSE

To translate and test the reliability and validity of a Persian translation of the Refractive Status and Vision Profile (RSVP), a vision-related quality of life questionnaire, in Iran.

METHODS

Forward & backward translation, committee review and pilot testing were performed to develop a final Iranian version of the RSVP. Seventy-three consecutive patients with refractive error before or after refractive surgery at the LASIK ward of Farabi Eye Hospital completed the questionnaire. A convenience sample of 14 patients completed the questionnaire twice within one week. Reliability was measured by internal consistency (Cronbach's alpha) and the intraclass correlation coefficient for test-retest reliability. Validity was evaluated by correlation between the different RSVP subscales, known groups comparison analysis, and correlation between the subscales versus global items and traditional clinical measures.

RESULTS

Internal consistency was high (Cronbach's alpha : 0.71-0.92; except for the subscale expectations, alpha : 0.6). Test-retest reliability of subscales and the overall RSVP scale, as estimated by the intraclass correlation coefficient, was high except for optical problems and glare. Comparisons between pre- and post-operative groups of patients showed significantly higher (worse) scores for concern, physical/social functioning, and the overall score in the pre-operative group. Almost all subscales showed desirable inter-scale correlations.

CONCLUSION

The Iranian version of the RSVP is a reliable and valid measure of vision-related quality of life in patients with refractive error.

Clinical trials - more than an assessment of treatment effect: LXV Edward Jackson Memorial Lecture

PURPOSE

To review the development of clinical trials and demonstrate their value beyond the assessment of the treatment effect.

DESIGN

Retrospective literature review.

METHODS

Retrospective literature review.

RESULTS

There has been a rapid increase in the number of clinical trials in ophthalmology as assessed by the number of ophthalmic publications and the number of ongoing National Eye Institute-(NEI) sponsored clinical trials over the last four decades. The public health significance of the results of these NEI clinical trials goes beyond the demonstration of treatment effects and side effects. From these trials, we learn about the clinical course and risk factors of disease, allowing us to better determine who and when to treat. Furthermore, the collaboration of investigators, as they develop and carry out protocols, facilitates incorporation of new ideas into the practice of medicine.

CONCLUSIONS

The practice of medicine is increasingly dependent on the results of carefully designed clinical trials. The determination as to whether a new treatment is safe and effective is important, but the additional information we can obtain regarding natural history, risk factors, and patient satisfaction adds immeasurably to our ability to care for our patients.

Visual performance of patients with bilateral vs combination Crystalens, ReZoom, and ReSTOR intraocular lens implants

PURPOSE

To compare the visual performance of patients with bilateral vs combination Crystalens, ReZoom, and ReSTOR intraocular lens (IOLs) implants.

DESIGN

Prospective, nonrandomized study.

METHODS

Forty-nine patients were implanted with bilateral Crystalens (Eyeonics, Aliso Viejo, California, USA), ReSTOR (Alcon Laboratories, Fort Worth, Texas, USA), and ReZoom (American Medical Optics, Santa Clara, California, USA) or combined Crystalens and ReSTOR or Crystalens and ReZoom IOLs after phacoemulsification. Monocular and binocular testing four to six months after surgery included uncorrected and best-spectacle corrected visual acuity at distance, intermediate, and near vision; mesopic contrast sensitivity function with and without glare; and quality-of-life and vision surveys six months after surgery.

RESULTS

Monocular testing showed that eyes with Crystalens accommodating IOL had statistically better best-spectacle corrected distance, uncorrected and distance-corrected intermediate, and best-corrected near vision. Eyes with the ReSTOR multifocal IOL had better uncorrected near vision, required the lowest reading add, and had the lowest uncorrected and distance-corrected intermediate vision. Monocular mesopic contrast sensitivity with and without glare was better with the Crystalens IOL vs either multifocal IOL at specific spatial frequencies. The binocular subjective quality of vision and quality of life questionnaires were favorable for the bilateral Crystalens group.

CONCLUSIONS

Any combination of Crystalens in one or both eyes was better for intermediate vision. Any combination of ReSTOR in one or both eyes was better for near vision. The Crystalens and ReSTOR combination had better mean intermediate and near vision overall. A multifocal IOL in one or both eyes was associated with lower contrast sensitivity and more subjective reports of photic phenomena. The accommodating and multifocal IOL combinations elicited less night glare symptoms than in patients with either bilateral multifocal IOL, but more than with bilateral Crystalens implantation.

The Development, Assessment, and Selection of Questionnaires

Patient-reported outcome measurement has become accepted as an important component of comprehensive outcomes research. Researchers wishing to use a patient-reported measure must either develop their own questionnaire (called an instrument in the research literature) or choose from the myriad of instruments previously reported. This article summarizes how previously developed instruments are best assessed using a systematic process and we propose a system of quality assessment so that clinicians and researchers can determine whether there exists an appropriately developed and validated instrument that matches their particular needs. These quality assessment criteria may also be useful to guide new instrument development and refinement. We welcome debate over the appropriateness of these criteria as this will lead to the evolution of better quality assessment criteria and in turn better assessment of patient-reported outcomes.