The development of the Indian vision function questionnaire: field testing and psychometric evaluation

A randomized sham-controlled trial of transcranial and intranasal photobiomodulation in Japanese patients with mild cognitive impairment and mild dementia due to Alzheimer's disease: a protocol

Introduction

Photobiomodulation (PBM) is a novel strategy for cognitive enhancement by improving brain metabolism and blood flow. It is potentially beneficial for patients with Alzheimer's disease (AD). We present a study protocol for a randomised controlled trial designed to evaluate the efficacy and safety of PBM.

Method and analysis

This is a single-centre, parallel-group, randomised, sham-controlled study. We enroll patients with mild cognitive impairment or dementia due to AD and assigned them to receive either active or sham stimulation at home for 12 weeks, with three sessions per week (20 min each). The stimulation involves invisible near-infrared light delivered by five applicators (one in a nostril, one on the frontal scalp, and three on the occipital scalp). The primary outcome will be the mean change in the Alzheimer Disease Assessment Scale-cognition from baseline to Week 12. We will also measure cognitive function, activity of daily living, behavioral and psychological symptoms, and caregiver burden. We will collect data at clinics at baseline and Week 12 and remotely at home. We estimate a sample size of 30 (20 active and 10 sham) based on an expected mean difference of -6.9 and an SD of 4.8. We use linear models for the statistical analysis.

Ethics and dissemination

The National Center of Neurology and Psychiatry Clinical Research Review Board (CRB3200004) approved this study. The results of this study will be published in a scientific peer-reviewed journal. Trial registration details Japan Registry of Clinical Trials jRCTs032230339.

Association between Quality of Life and Visual Acuity in a Randomized Clinical Trial of Patients with Uveitis Taking Antimetabolites

PURPOSE

To evaluate how changes in visual acuity are associated with changes in quality of life (QoL) among patients with non-infectious uveitis taking antimetabolites.

METHODS

This secondary analysis of the multicenter First-line Antimetabolites as Steroid-sparing Treatment (FAST) Uveitis Trial involves 216 participants randomized to methotrexate or mycophenolate mofetil. Vision-related (NEI-VFQ and IND-VFQ) and health-related (PCS and MCS SF-36v2) QoL and visual acuity were measured at baseline and 6-month primary endpoint.

RESULTS

Visual acuity was significantly associated and correlated with all QoL measures (Spearman correlation coefficients = 0.5, 0.5, 0.3, and 0.4 for NEI-VFQ, IND-VFQ, SF-36v2 MCS and PCS, respectively). All observed changes in QoL met or exceeded the minimal clinically important difference definition on each scale. Treatment group was not significantly associated with any QoL measure.

CONCLUSION

By adding insight beyond visual acuity, QoL provides a more comprehensive picture of the patient experience during uveitis treatment.Abbreviations and Acronyms: QoL = quality of life; VR-QoL = vision-related quality of life; HR-QoL = health-related quality of life; FAST = First-line Antimetabolites as Corticosteroid Sparing Treatment; NEI-VFQ = National Eye Institute Visual Functioning Questionnaire; IND-VFQ = Indian Visual Functioning Questionnaire; SF-36v2 = Medical Outcomes Study 36-Item Short Form Survey; PCS = physical component score; MCS = mental component score; 95% CI = 95% confidence interval; MCID = minimal clinically important difference.

Depressive and generalized anxiety symptoms in adults awaiting cataract surgery in India

Background Systematic data on mental health issues among adults awaiting cataract treatment are not readily available in India. We explored the prevalence and predictors of depressive and generalized anxiety (GA) symptoms in a cohort of adults awaiting cataract surgery. Methods Our study is based on data from baseline assessments which were conducted as part of a multicentre prospective, longitudinal cohort study. Subjects were recruited from four eye hospitals to assess depression and GA and associated risk factors using standardized scales, i.e. Center for Epidemiologic Studies-Depression Scale (CES-D) and Generalised Anxiety Disorder (GAD-7). Variation in the intensity of depression and GA was assessed using multiple classification analysis (MCA). Results A total of 813 adults awaiting cataract surgery participated, of whom 456 (56.1%) were men. The mean (SD) CES-D and GAD-7 scores were 24.6 (7.8) and 6.3 (SD 4.2) for men and 25.8 (8.9) and 6.9 (4.4) for women, respectively. The overall prevalence of depression score of >16 was 87.4% (95% confidence interval [CI] 84.7%- 89.6%), and GA score of >10 was 57.1% (95% CI 53.5%-60.7%). The prevalence of comorbid depressive and anxiety symptoms was 56.6% (95% CI 52.9%- 60.2%). MCA showed that being neglected and mistreated by family/friends because of vision condition and facing difficulty and requiring help with daily tasks had the highest effect on the intensity of both depression (beta=0.254 and 0.238, respectively) and GA (beta=0.219 and 0.211, respectively). Conclusion The majority of adults with untreated cataract had both depressive and GA symptoms. These findings could be used for planning mental health interventions for adults awaiting cataract surgery.

Impact of glaucoma on vision-specific quality of life in monocular glaucoma patients using the Indian vision function questionnaire

Purpose

To evaluate the determinants affecting the quality of life in monocular glaucoma patients using the Indian vision function questionnaire.

Methods: In this prospective cross-sectional study,

total of 196 patients were divided into two groups: cases and controls. Indian Vision Function Questionnaire (IND-VFQ) was administered and analyzed. One hundred twenty-nine (58.6%) patients who had lost their vision in one eye due to glaucoma were included as cases and 67 (30.4%) patients who had lost their vision due to other causes were taken as controls.

Results

Median composite score of subscales was 54.62 (29.7-74.7) in group 1 and 45.38 (23.7-76.7) in group 2. The psychosocial impact scale was the most affected scale, the median scores were 33.02 (0 to 60.0) and 19.07 (0 to 53.0) in groups 1 and 2, respectively. Among all dimensions of IND-VFQ, the highest score was for color vision 100.0 (0-100.0) and 100.0 (0-100.0), and the lowest median score was found in mental health and dependency in both the groups. Multiple linear regression analysis demonstrated that visual acuity was associated with a low score (P < 0.001). Female gender was significantly associated with the overall score in the univariate model (P = 0.006).

Conclusion

Monocular glaucoma patients have a poor general and vision-related quality of life. Depression associated with monocularity and the perception of dependency and being a burden on their family members greatly impacted the mental health of the participants.

Unilateral Vision Loss in Elderly People in Residential Care: Prevalence, Causes and Impact on Visual Functioning: The Hyderabad Ocular Morbidity in Elderly Study (HOMES)

PURPOSE

To investigate the prevalence, causes and impact of unilateral visual impairment (UVI) on visual function in the elderly in 'home for the aged' in Hyderabad, India.

METHODS

Participants aged ≥60 years were recruited from 41 'homes for the aged'. All participants had complete eye examinations including visual acuity assessment, refraction, slit-lamp and fundus examination. Unilateral visual impairment (UVI) was defined as presenting VA worse than 6/18 in one eye and presenting VA 6/18 or better in the other eye. Indian Vision Function Questionnaire (INDVFQ) was used for assessing visual functioning.

RESULTS

Of the total 1,513 elderly participants enumerated, 1,182 (78.1%) were examined. After excluding 356 participants with VI in the better eye, data were analysed for the remaining 826 participants. The mean age (standard deviation) of these participants was 74.4 ± 8.4 years; 525 (63.6%) were women, and 111 (13.4%) had no schooling. The prevalence of unilateral VI was 38.1% (95% CI: 34.8-41.5; n = 315). Cataract (37.5%; n = 118) was the leading cause of UVI followed by Uncorrected Refractive Error (22.2%; n = 70) and posterior capsular opacification (18.4%; n = 58). The overall INDVFQ score was higher among those with UVI than those without UVI (37.7 versus 34.5; p < .01) suggestive of poor visual functioning.

CONCLUSIONS

UVI was common and largely due to avoidable causes among the elderly in residential care with an adverse impact on visual functioning. Screening for vision loss in 'homes for the aged' and the provision of appropriate services should become a routine practice to achieve the goal of healthy aging in India.

Impact of an intervention for avoidable vision loss on visual function in the elderly-The Hyderabad Ocular Morbidity in Elderly Study (HOMES)

BACKGROUND/OBJECTIVES

To report the impact of interventions for avoidable vision impairment (VI) on the visual function of elderly residents in 'homes for the aged' in India.

METHODS

Participants aged ≥60 years were recruited. A comprehensive eye examination was conducted by trained examiners and interventions were provided. Trained social investigators administered the Indian Vision Function questionnaire (INDVFQ) to assess visual function before and after the intervention (spectacles, cataract surgery or laser capsulotomy). Lower scores on IVFQ imply better visual function. VI was defined as presenting visual acuity worse than 6/18 in the better eye. VI due to cataract, uncorrected refractive errors, and posterior capsular opacification after cataract surgery were considered avoidable VI.

RESULTS

The mean age of the participants (n = 613) was 73.8 years (standard deviation: 8.1 years) and 378 (62.2%) were women. 64/103 (62.1%) participants who had avoidable VI at baseline were evaluated after the intervention. Significant gains were observed in all four domains of visual function. There was a 14.9% improvement in mobility scores (33.8 versus 28.8; p = 0.03), a 19.9% improvement in the activity limitations score (36.8 versus 29.5; p < 0.01), a 10.9% improvement in the psychosocial impact score (41.1 versus 36.6; p < 0.01) and a 13.6% improvement in the visual symptoms score (49.2 versus 42.5 p < 0.01). Overall, the mean IVFQ score improved by 16.4% (47.6 versus 39.8; p < 0.01).

CONCLUSION

Elderly individuals in residential care with avoidable VI had a significant improvement in visual function after relatively low-cost interventions such as spectacles and cataract surgery. Strategies are needed to provide these interventions for the elderly in 'homes for the aged' in India.

Population-based study on the prevalence, clinical characteristics and vision-related quality of life in patients with corneal opacity resulting from infectious keratitis: results from the Corneal Opacity Rural Epidemiological study

AIM

To estimate prevalence and characterise clinical features and vision-related quality of life (VR-QoL) of corneal opacities (COs) resulting from infectious keratitis in a rural North Indian population.

METHODS

The Corneal Opacity Rural Epidemiological study was a cross-sectional study conducted in 25 randomly selected clusters of rural Gurgaon, Haryana, India to determine prevalence of corneal disease across all age groups. During house-to-house visits, sociodemographic details, presence, type and clinical characteristics of corneal disease, laterality and resultant visual impairment (VI) was noted. Subgroup analysis of data was performed to understand the prevalence, clinical characteristics, VR-QoL in patients with CO due to infectious keratitis. VR-QoL scores were compared with healthy controls.

RESULTS

Overall, 65 of 12 113 participants had evidence of infectious keratitis-related CO with a mean age of 63.3 (±14.7 SD) years. Prevalence of infectious keratitis-related CO, including both bilateral (12/65) and unilateral (53/65) cases was 0.54% (95% CI 0.41 to 0.66) seen in a total of 77 eyes of 65 participants. Mean visual acuity was 1.18±0.80 with 30/77 (38.9%) eyes having a presenting visual acuity <3/60. Most of the CO due to infectious keratitis was <3 mm in size (61.03%; 47/77), nebular (42.85%; 33/77) and central (49.35%; 38/77) in location. These participants had significantly higher VR-QoL scores and hence poorer VR-QoL across all three domains of vision function (scores of 28 vs 22, 7.5 vs 5 and 15.5 vs 9, respectively; p<0.0001) when compared with healthy controls.

CONCLUSION

The data from this study give an insight into the burden and clinical characteristics of COs resulting from infectious keratitis. VR-QoL is significantly impaired in patients with CO resulting from infectious keratitis, both in bilateral and unilateral cases.

The Psychological Impact of Rhino-Orbital Mucormycosis During the Second Wave of COVID-19 Pandemic From South East Asian Country

AIM

The present study addressed overcoming the lacunae in the literature of psychiatric manifestations associated with rhino-orbital mucormycosis. The current study aimed to assess the symptoms of depression, anxiety, stress, coping measures, suicidal intent, and visual disability in patients of rhino-orbital mucormycosis (ROM) during the epidemic of the disease at the nodal tertiary care center in North India.

METHODS

Fifty-four inpatients of laboratory-proven rhino-orbital mucor-mycosis (ROM) were included for an observational, cross-sectional study at nodal, designated COVID-19, and mucormycosis treating tertiary care hospital. Patients with Hindi Mini-Mental State Examination score <24, prior psychiatric illness, and severely ill requiring ventilator support were excluded. The psychological variables were assessed using Depression, Anxiety, and Stress Scale 21 (DASS 21), Beck's Suicide intent Scale, Coping Scale Questionnaire, and Visual disability scale (IND-VFQ33). Their socioeconomic status was assessed using the Modified Kuppuswamy Scale.

RESULTS

Ninety percent of patients with ROM had diabetes mellitus. The majority (44%) of patients belonged to lower socioeconomic strata. Higher frequencies of severe depression (28%), extremely severe anxiety (26%), and mild stress (17%) were noted in the study participants. On the Tukey test, depression score was higher in patients of ROM compared to COVID (with ROM) (p-value= 0.016). On Tukey analysis, anxiety score was significantly higher in ROM patients compared to COVID (with ROM) patients (p-value = 0.018). Coping scores were significantly higher in COVID (with ROM) patients compared to ROM patients (p value = 0.035). Mild to moderate visual disability was noted in the study participants.  Conclusion: The current study reflects the association of higher depression and anxiety scores in cases with ROM that indicated higher mental health needs. Early assessment, early detection, and early intervention for psychological help, along with the multidisciplinary team, helped to improve the overall psychological outcome of the affected patients.

Vision-related quality of life and psychosocial well-being of patients with episcleritis and scleritis: a neglected essence?

BACKGROUND

To assess the change in vision-related quality of life and psychosocial well-being of the patients with episcleritis and scleritis patients before and after treatment.

RESULTS

This one-and-a-half-year prospective study was conducted among 76 eyes of 71 new patients of episcleritis and scleritis. A structured questionnaire was used to assess the visual and to analyze the change in effect size. The male-to-female ratio was 1:1.536. Episcleritis was seen in 41 cases (57.7%) while scleritis was seen in 30 cases (42.3%). Patients with episcleritis had statistically significant improvement in general function score (GF) (p < 0.05) using paired t-test. The effect size showed medium improvement (approximately 0.5). Whereas there was no statistically significant change in psychosocial impact (PI), visual symptoms (VS) scoring, and a total score (p < 0.05) using paired t-test. The effect size showed no improvement for PI and total score and small improvement for VS score. Patients with scleritis had statistically significant improvement in general function score (GF), visual symptoms (VS) scoring and total score (p < 0.05) using paired-t-test. The effect size showed medium improvement (approximately 0.5) for general function score (GF) and total score. However, the effect size showed only a small improvement (approximately 0.2) for psychosocial impact (PI) score.

CONCLUSIONS

VisionRelated Quality of Life of patients with scleritis showed significant improvement following treatment unlike episcleritis indicating scleritis more adversely affecting psychosocial well-being.

Demographic and clinical profile, surgical outcome, and quality of life in patients who underwent bilateral lamellar corneal grafts

Purpose:

Lamellar corneal grafts have revolutionized the management of corneal blindness by replacing only the disease specific corneal layers. To the best of our knowledge, there is no study in literature describing the outcomes of bilateral lamellar keratoplasty in the Indian population. The aim of this work was to study the demographic profile, surgical outcomes, and quality of life in patients who underwent bilateral lamellar keratoplasty and to assess the correlation between these three.

Methods:

An observational cross-sectional study was conducted on 47 patients who underwent bilateral deep anterior lamellar keratoplasty (DALK) (n = 31) or descemet stripping automated endothelial keratoplasty (DSAEK) (n = 16) with a minimum follow-up of 6 months after the second surgery. Demographic parameters were collected by interview, surgical outcomes by clinical examination, and quality of life by a questionnaire.

Results:

A total of 47 patients were evaluated, women 42.56%, (n = 20) and men 57.44% (n = 27) with 38.3% being in 18–30 years age group and 23.4% above 60 years; 17.02% patients had a good socioeconomic status (score >60) and 61.70% had poorer socioeconomic status (score <50). Quality of life score (VR-QoL) was ≥50 in 82.9% patients and ≥70 in 14.89%. No significant association existed between VR-QoL scores and demographic factors. However, statistically significant association existed between VR-QoL and age of patient (P < 0.05), postoperative vision (P ≤ 0.05), and contrast sensitivity (P ≤ 0.01).

Conclusion:

Bilateral lamellar corneal grafts provide satisfactory visual outcomes compatible with day-to-day functioning. VR-QoL has a direct correlation to the age, visual acuity, contrast sensitivity, and inverse correlation with lenticule thickness in DSAEK and residual bed thickness in DALK.

Psychometric Assessment of the Chinese Version of the Indian Vision Functioning Questionnaire Based on the Method of Successive Dichotomizations

Purpose

The purpose of this study was to assess whether a Chinese translated version of the 33-item Indian Vision Function Questionnaire (IND-VFQ-33) forms a valid measurement scale and to evaluate its psychometric properties based on the method of successive dichotomizations (MSD).

Methods

The English version of the IND-VFQ-33 was translated, back translated, and cross-culturally adapted for use in China. It was interviewer administered to patients with cataracts. MSD, a polytomous Rasch model that estimates ordered thresholds, was used to assess and optimize psychometric properties of the overall scale and three subscales separately.

Results

One hundred and seventy-nine patients provided complete responses. After the removal of 2 misfitting items, a revised 31-item overall scale demonstrated adequate precision (person reliability [PR] = 0.92) and no misfitting items. The general functioning subscale fit the MSD model well after removing two misfitting items. The psychosocial impact subscale and the visual symptoms subscale were not considered further due to poor measurement precision. After addressing psychometric deficiencies, a 31-item overall scale (IND-VFQ-31-CN) and a 19-item general functioning subscale (IND-VFQ-GF-19-CN) were developed.

Conclusions

The original IND-VFQ-33 required re-engineering to form valid measures for use in China. The revised overall scale and general functioning subscale demonstrated adequate MSD based psychometric properties.

Translational Relevance

The revised IND-VFQ-33 is a valid patient-reported outcome assessment for Chinese patients with cataract based on MSD analysis.

Health- and Vision-Related Quality of Life in a Randomized Controlled Trial Comparing Methotrexate and Mycophenolate Mofetil for Uveitis

PURPOSE

To evaluate changes in health-related and vision-related quality of life (VRQoL) among patients with noninfectious uveitis who were treated with antimetabolites.

DESIGN

Secondary analysis of a randomized controlled trial.

PARTICIPANTS

Patients with noninfectious uveitis from India, the United States, Australia, Saudi Arabia, and Mexico.

METHODS

From 2013 through 2017, 216 participants were randomized to receive 25 mg weekly oral methotrexate or 1.5 g twice daily oral mycophenolate mofetil. Median changes in quality of life (QoL) were measured using Wilcoxon signed-rank tests, and differences between treatment groups were measured using linear mixed models, adjusting for baseline QoL score, age, gender, and site. Among Indian patients, VRQoL scores from a general scale (the National Eye Institute Visual Function Questionnaire [NEI-VFQ]) and a culturally specific scale (the Indian Visual Function Questionnaire [IND-VFQ]) were compared using Pearson correlation tests.

MAIN OUTCOME MEASURES

Vision-related QoL (NEI-VFQ and IND-VFQ) and health-related QoL (HRQoL; physical component score [PCS] and mental component score [MCS] of the Medical Outcomes Study 36-Item Short Form Survey [SF-36v2]) were measured at baseline, the primary end point (6 months or treatment failure before 6 months), and the secondary end point (12 months or treatment failure between 6 and 12 months).

RESULTS

Among 193 participants who reached the primary end point, VRQoL increased from baseline by a median of 12.0 points (interquartile range [IQR], 1.0-26.1, NEI-VFQ scale), physical HRQoL increased by a median of 3.6 points (IQR, -1.4 to 14.9, PCS SF-36v2), and mental HRQoL increased by a median of 3.0 points (IQR, -3.7 to 11.9, MCS SF-36v2). These improvements in NEI-VFQ, SF-36v2 PCS, and SF-36v2 MCS scores all were significant (P < 0.01). The linear mixed models showed that QoL did not differ between treatment groups for each QoL assessment (NEI-VFQ, IND-VFQ, PCS SF-36v2, and MCS SF-36v2; P > 0.05 for all). The NEI-VFQ and IND-VFQ scores for Indian participants were correlated highly at baseline and the primary and secondary end points (correlation coefficients, 0.87, 0.80, and 0.90, respectively).

CONCLUSIONS

Among patients treated with methotrexate or mycophenolate mofetil for uveitis, VRQoL and HRQoL improved significantly over the course of 1 year and did not differ by treatment allocation. These findings suggest that antimetabolites could improve overall patient well-being and daily functioning.

Psychometric validation techniques applied to the IND-VFQ-33 visual function questionnaire: the Hyderabad ocular morbidity in the elderly study (HOMES)

BACKGROUND

Over 2 billion people suffer from vision impairment or blindness globally, and access to validated visual measurement tools in imperative in accurately describing and managing the burden of eye disease. The present study applies contemporary psychometric validation techniques to the widely used 33-item Indian Visual Function Questionnaire (IND-VFQ-33).

METHODS

We first estimated the polychoric correlation between each pair of items. Next, an unrotated and oblique Promax rotated factor analysis, item response theory (IRT, using a graded response model (GRM)), and differential item functioning (DIF) testing were applied to the IND-VFQ-33. We subsequently propose a validated IND-VFQ-33 questionnaire after psychometric testing, data reduction, and adjustment.

RESULTS

Exploratory unrotated factor analysis identified two factors; one with a particularly high eigenvalue (18.1) and a second with a lower eigenvalue still above our threshold (1.1). A subsequent oblique Promax factor rotation was undertaken for a 2-factor solution, revealing two moderately correlated factors (+ 0.68) with clinically discrete item loadings onto either Factor 1 (21 items; collectively labelled "daily activities") or Factor 2 (5 items; collectively labelled "bright lights"). IRT confirmed high item discrimination for all remaining items with good separation between difficulty thresholds. We found significant DIF on depression for six items in Factor 1 (all uniform DIF, except item 21 (non-uniform DIF) with no substantive difference in beta thresholds for any item and no substantive difference in expected individual or sum score, by depression at baseline. For Factor 2, only one item demonstrated significant uniform DIF on gender, similarly without major differences in beta thresholds or expected total score between gender at baseline. Consequently, no further item recalibration or reduction was undertaken after IRT and DIF analysis.

CONCLUSION

Applying IRT and DIF validation techniques to the IND-VFQ-33 identified 2 discrete factors with 26 uniquely-loading items, clinically representative of difficulty performing daily activities and experiencing difficulty due to bright lights/glare respectively. The proposed modified scale may be useful in evaluating symptomatic disease progression or response to treatment in an Indian population.

Impact of Vision Loss on Visual Function Among Elderly Residents in the "Home for the Aged" in India: The Hyderabad Ocular Morbidity in Elderly Study

Purpose

The purpose of this study was to report the association between visual impairment (VI) and self-reported visual difficulty among the elderly in residential care using the Indian Vision Functioning Questionnaire (IND-VFQ-33) psychometrically validated questionnaire.

Methods

Participants aged ≥ 60 years were recruited from 41 homes in Hyderabad in South India. All participants underwent detailed eye examination and interviews. Self-reported visual function was assessed using the IND-VFQ-33 questionnaire. Factor Analysis and Item Response Theory (IRT) models were used for analysis. Multivariable regression models were used to investigate associations between derived global difficulty scores versus severity and causes of VI. Presenting visual acuity worse than 6/18 in the better eye was considered as VI.

Results

In total, 867 elderly participants completed the INDVFQ-33. Two latent traits ("daily activities" and "visual symptoms") were identified on factor analysis, each with uniquely loading questions. Participants with VI reported significantly higher daily activities difficulty (6 points higher) and visual symptoms difficulty (1.7 points higher) than those without VI (P < 0.05). Those with cataract reported the highest daily activities and visual symptoms difficulty (7.6 points and 2.2 points higher, respectively, P < 0.05). Greater severity of VI was associated with increased self-reported difficulty for both factors, and for all causes of VI.

Conclusions

We present a psychometrically validated visual questionnaire particularly suited to older adults in residential homes. We show a significant association between cause/severity of VI and difficulty with daily activities and visual symptoms after adjusting for sociodemographic and medical factors.

Translational Relevance

Understanding the impact of vision loss on visual functions in the elderly will help in planning and resource allocation for developing early intervention programs for the elderly.

Comparison of Post-Cataract Surgery Visual Outcomes and Quality of Life in Patients Bilaterally Implanted with Multifocal Intraocular Lenses

Introduction

The present study compared visual outcomes in eyes with bilateral implantation of two multifocal intraocular lenses (MFIOLs)—the Eyecryl™ ACTV diffractive multifocal IOL (group 1) and AcrySof^® IQ ReSTOR^® multifocal IOL (group 2).

Methods

This was a prospective, two-group observational longitudinal study of 118 eyes from 59 patients conducted at Laxmi Eye Institute, Panvel, India. We evaluated the patients at 1, 3, and 6 months. We assessed visual acuity, contrast sensitivity, higher-order aberrations, reading speed, defocus curve, stereopsis, quality of life (QOL), and adverse events in these participants.

Results

The median (interquartile range) best-corrected distance visual acuity was 0.18 (0, 0.18) in group 1 and 0.18 (0, 0.18) in group 2 at 1, 3, and 6 months; the difference was not statistically significant (p = 0.48). The binocular defocus curve in both groups showed two peaks at 0.0 to −0.5 D and at −2.5 D. The mean (95% confidence interval) critical print size was significantly different between groups 1 and 2 at low illumination (0.918 [0.905, 0.931] vs 1.154 [1.128, 1.180]; p = 0.004). Contrast sensitivity was significantly better in group 1 under mesopic conditions but not under scotopic conditions. Though total QOL did not differ significantly between groups, the psychosocial quality of life was significantly better in group 1. About 23% of patients in group 2 reported unwanted images, compared with 0% in group 1 (p = 0.01).

Conclusion

We found that the Eyecryl and AcrySof groups were comparable for best-corrected visual acuity, photopic contrast sensitivity, defocus curve, reading parameters, stereopsis, and quality of vision. However, the Eyecryl group had better mesopic contrast and a lower proportion of unwanted images. Psychosocial quality of life was significantly better in the Eyecryl group; however, satisfaction was similar between groups. The cost of one of the lenses is less than the other. Thus, individuals with limited resources may opt for the Eyecryl™ ACTV, with similar visual outcomes.

Generic and vision related quality of life associated with different types of cataract surgeries and different types of intraocular lens implantation

OBJECTIVES

To assess the effects of different types of cataract surgeries and intraocular lenses on generic as well as vision related quality of life of cataract patients, using EQ-5D and IND-VFQ 33 instruments respectively.

METHODS

An observational, longitudinal study of patients undergoing cataract surgery was carried out at three ophthalmology centres. Patients were prospectively admitted for surgery for age-related cataract. Generic quality of life was assessed by using Euroqol's EQ5D-5L questionnaire and vision related quality of life was assessed by the IND-VFQ-33 questionnaire. Data pertaining to vision function and quality of life were collected pre surgery and 4 weeks after the surgery.

RESULTS

Out of total patients (n = 814) recruited for the study, 517 patients were interviewed for both pre-surgery and post-surgery for EQ5D and 519 patients were interviewed for both pre-surgery and post-surgery for IND VFQ 33 tool. The combined data from all three centres showed that Quality Adjusted Life Year (QALY) gains observed in patients undergoing phacoemulsification with foldable lens implantation (2.25 QALY) were significantly higher (0.57 QALY) as compared to Small Incision Cataract Surgery (SICS) with PMMA lens implantation (1.68 QALY). Highest improvement however, in all three subscales of IND-VFQ-33 tool were clearly observed for SICS with PMMA lens implantation.

CONCLUSIONS

The study has elicited the Health related and vision related Quality of Life scores for cataract surgeries and subsequent lens implantation. This study also offers Health State Utility Values along with visual outcomes for different surgical procedures, lenses and for the combination of surgery with lens implantation for cataract procedures providing a useful resource for future economic evaluation studies.

Glaucoma-Associated Visual Task Performance and Vision-Related Quality of Life in South India

OBJECTIVE/PURPOSE

Performance-based measures may provide an objective assessment of how glaucoma affects daily functioning. We sought to validate a clinically-applicable performance-based measure of visual ability for patients with glaucoma in south India and to describe its relationship to clinical and patient-reported outcomes.

DESIGN

Cross-sectional validation study.

SUBJECTS/PARTICIPANTS/CONTROLS

145 participants with glaucoma were recruited at Aravind Eye Hospital.

METHODS/INTERVENTION/TESTING

We modified the compressed assessment of activities related to vision (CAARV), a performance-based measure validated in the U.S., to be culturally relevant in south India. Participants underwent a series of tests, including the Indian CAARV (I-CAARV), Indian Visual Functioning Questionnaire (IND-VFQ), Spaeth/Richman Contrast Sensitivity (SPARCS) test, standard automated perimetry, and visual acuity (VA). Factor analysis and Rasch modeling were used to validate the I-CAARV. Correlations between the I-CAARV and other outcomes were evaluated.

MAIN OUTCOME MEASURE

Psychometric properties of the I-CAARV for individuals with glaucoma in south India.

RESULTS

The study included 142 participants (51.7% female, mean age 56.4 years). Average presenting visual acuity and visual field mean deviation (MD) in the better-seeing eye were 0.26 logMAR and -6.57 dB, respectively. The four tasks of the I-CAARV were found to measure a single underlying construct. Rasch analysis of the I-CAARV revealed that the outcome measure had moderate reliability, good construct and content validity, and fair measurement precision. Tasks were well-targeted to the study sample. Rasch-calibrated scores on the I-CAARV were significantly correlated with Rasch-calibrated IND-VFQ scores (r=-0.54) and with visual field MD, presenting VA, best-corrected VA, and SPARCS contrast sensitivity in both the better-seeing eye (r=0.60, -0.51, -0.53, 0.76, respectively) and worse-seeing eye (r=0.48, -0.61, -0.46, 0.69, respectively).

CONCLUSIONS

The I-CAARV is a valid performance-based measure of vision-dependent functioning in glaucoma in south India. This study also found that I-CAARV task performance was strongly correlated with contrast sensitivity and suggests that performance-based and patient-reported outcomes are related but distinct measures of the impact of glaucoma on functioning and vision-related quality of life. Future studies are needed to determine the sensitivity of the I-CAARV to detect changes due to disease progression that are relevant to functioning and vision-related quality of life.

Coping strategy in persons with low vision or blindness - an exploratory study

Purpose:

Coping strategies employed by people with visual disability can influence their quality of life (QoL). We aimed to assess coping in patients with low vision or blindness.

Methods:

In this descriptive cross sectional study, 60 patients (25–65 years) with <6/18 best-corrected vision (BCVA) in the better eye and vision loss since ≥6 months were recruited after the institutional ethics clearance and written informed consent. Age, gender, presence of other chronic illness, BCVA, coping strategies (Proactive Coping Inventory, Hindi version), and vision-related quality of life (VRQoL; Hindi version of IND-VFQ33) were recorded. Range, mean (standard deviation) for continuous and proportion for categorical variables. Pearson correlation looked at how coping varied with age and with VRQoL. The analysis of variance (ANOVA) and t-test compared coping scores across categorical variables. Statistical significance was taken at P < 0.05.

Results:

Sixty patients fulfilled inclusion criteria. There were 33 (55%) women; 25 (41.7%) had low vision, 5 (8.3%) had economic blindness, and 30 (50.0%) had social blindness; 27 (45.0%) had a co-morbid chronic illness. Total coping score was 142 ± 26.43 (maximum 217). VRQoL score (maximum 100) was 41.9 ± 15.98 for general functioning; 32.1 ± 12.15 for psychosocial impact, and 41.1 ± 17.30 for visual symptoms. Proactive coping, reflective coping, strategic planning, and preventive coping scores correlated positively with VRQoL in general functioning and psychosocial impact.

Conclusion:

Positive coping strategies are associated with a better QoL. Ophthalmologists who evaluate visual disability should consider coping mechanisms that their patients employ and should refer them for counseling and training in more positive ways of coping.

Prevalence of visual impairment and its association with vision-related quality of life among elderly persons in a resettlement colony of Delhi

Background:

The population of India is ageing. The number and percentage of elderly persons is increasing. Visual impairment is common among elderly persons and affects their vision-related quality of life. The objective of this study was to estimate the prevalence of visual impairment among elderly persons aged 60 years and above residing in a resettlement colony of Delhi and study its association with socio-demographic variables and vision-related quality of life.

Methods:

A total of 604 elderly participants were selected by simple random sampling. House-to-house visit was done, and a self-developed pre-tested semi-structured interview schedule was used to collect socio-demographic information. Visual acuity was measured using Snellen's chart, and distant direct ophthalmoscopy was done to diagnose cataract. Vision-related quality of life was assessed by Indian Vision Function Questionnaire-33 (IND-VFQ-33).

Results:

Of the 604 participants, 555 (91.9%) were available for interview. The prevalence of visual impairment was 24.5% (95% CI: 20.9% - 28.1%). Cataract was the leading cause of visual impairment (50.7%), followed by uncorrected refractive error (36.8%). Illiteracy (aOR: 3.49, 1.37-8.87), economic dependence on family members (aOR: 1.92, 1.04 – 3.54), not currently working (aOR: 1.89, 1.20-2.98) and chewing of tobacco products (aOR: 2.56, 1.48-4.42) were significantly associated with visual impairment among study participants. Vison-related quality of life was worse among those with visual impairment.

Conclusion:

Burden of visual impairment is high among elderly persons living in urban resettlement colonies. It is largely avoidable. Eye-care services should be accessible and affordable to them.

Development of a rapid point-of-care patient reported outcome measure for cataract surgery in India

Background

For patient undergoing cataract surgery in India, existing patient-reported outcome (PRO) measures are either not culturally relevant, have not been adequately validated, or are too long to be used in a busy clinical setting. We sought to develop and validate a brief and culturally relevant point-of-care PRO measure to address this need.

Methods

Twelve items from the Indian Visual Functioning Questionnaire (IND-VFQ) were selected based on preliminary data. Patients 18 years and older were prospectively recruited at Aravind Eye Care System in Madurai, India. Clinical and sociodemographic data were collected and the 12-item short-form IND-VFQ (SF-IND-VFQ) was administered pre- and post-operatively to 225 patients; Factor analysis and Rasch modeling was performed to assess its psychometric properties.

Results

One item that did not fit a unidimensional scale and had poor fit with the Rasch model was eliminated from the questionnaire. The remaining 11 items represented a single construct (no residual correlations> 0.1) and were largely unaffected by differential item functioning. Five items had disordered thresholds resolved by collapsing the response scale from four to three categories. The survey had adequate reliability (0.80) and good construct (infit range, 0.77–1.29; outfit range, 0.56–1.30) and content (item separation index, 5.87 logits) validity. Measurement precision was fair (person separation index, 1.97). There was evidence that items were not optimally targeted to patients’ visual ability (preoperatively, − 1.92 logits; overall, − 3.41 logits), though the survey measured a very large effect (Cohen’s d 1.80). In a subset of patients, the average time to complete the questionnaire was 2 min 6.3 s.

Conclusions

The SF-IND-VFQ is a valid, reliable, sensitive, and rapidly administered point-of-care PRO measure to assess changes in visual functioning in patients undergoing cataract surgery in India.

Electronic supplementary material

The online version of this article (10.1186/s12955-018-0855-5) contains supplementary material, which is available to authorized users.

Quality-of-Life Outcomes From a Randomized Clinical Trial Comparing Antimetabolites for Intermediate, Posterior, and Panuveitis

PURPOSE

To evaluate the changes in quality of life in noninfectious uveitis patients treated with 2 of the most commonly prescribed antimetabolite treatments.

DESIGN

Secondary analysis of a multicenter, block-randomized clinical trial.

METHODS

Eighty patients at Aravind Eye Hospitals in Madurai and Coimbatore, India, with noninfectious intermediate, posterior, or panuveitis were randomized to receive oral methotrexate, 25 mg weekly, or oral mycophenolate mofetil, 1 g twice daily, and were followed up monthly for 6 months. Best-corrected visual acuity, Indian Vision Function Questionnaire (IND-VFQ), and Medical Outcomes Study 36-item Short Form Survey (SF-36) were obtained at enrollment and at 6 months (or prior, in the event of early treatment failure).

RESULTS

IND-VFQ scores, on average, increased by 9.2 points from trial enrollment to 6 months (95% confidence interval [CI]: 4.9, 13.5, P = .0001). Although the SF-36 physical component summary score did not significantly differ over the course of the trial, the mental component summary score decreased by 2.3 points (95% CI: -4.4, -0.1, P = .04) and the vitality subscale decreased by 3.5 points (95% CI: -5.6, -1.4, P = .001). Quality-of-life scores did not differ between treatment arms. Linear regression modeling showed a 3.2-point improvement in IND-VFQ score for every 5-letter improvement in visual acuity (95% CI: 1.9, 4.3; P < .001).

CONCLUSIONS

Although uveitis treatment was associated with increased vision and vision-related quality of life, patient-reported physical health did not change after 6 months of treatment, and mental health decreased. Despite improved visual outcomes, uveitis patients receiving systemic immunosuppressive therapy may experience a deterioration in mental health-related quality of life.

Change in Visual Function in Uveitis Patients after Treatment: An Experience from Nepal

PURPOSE

To assess the change in visual function in uveitis patients after treatment.

MATERIALS AND METHODS

This one and a half year prospective study was conducted among 180 new uveitis patients. A questionnaire was used to assess the visual function in uveitis cases and analysis of effect size change was also done.

RESULTS

The male to female ratio was 1.3:1. The mean vision at presentation was 0.49 logMAR units, which improved to 0.39 logMAR units and 0.35 logMAR units by the 1st and 4th week but deteriorated to 0.62 logMAR units at the 6th week. Anterior uveitis and posterior uveitis patients had significant improvement (p≤0.001) in all three scales but panuveitis and intermediate uveitis had significant improvement (p<0.05) in two scales. The effect size showed small to large change in all three scales.

CONCLUSIONS

Visual function is adversely affected by uveitis, which can be improved after treatment.

Impact of initial topical medical therapy on short-term quality of life in newly diagnosed patients with primary glaucoma

Purpose:

To evaluate the impact of initial topical medical therapy on newly diagnosed glaucoma patients using the Indian Vision Function Questionnaire (IND-VFQ33).

Patients and Methods:

The IND-VFQ33 was used to evaluate the quality of life (QoL) in 62 newly diagnosed patients with moderate to severe primary glaucoma and 60 healthy controls. IND-VFQ33 is a 33 item QoL assessment tool with three domains: General functioning, psychosocial impact and visual symptoms. The glaucoma patients were started on medical therapy and the QoL assessment was repeated after 3 months.

Results:

Glaucoma patients (mean age: 55.6 ± 9.6 years, range 40–77 years) and controls (mean age: 54.9 ± 6.7 years, 42–73 years) were matched with respect to age (P = 0.72), gender (P = 0.91) and literacy (P = 0.18). Glaucoma patients had significantly worse QoL as compared to controls at baseline across all the three domains (P < 0.001). 3 months after initiation of treatment, the overall QoL life significantly worsened from baseline with a decrease in general functioning (P < 0.001) and psychosocial impact (P = 0.041). Visual acuity in better eye significantly co-related to poor QoL at baseline (P < 0.001) and at 3 months (P = 0.04). In addition, the use of >2 topical medications significantly co-related to poor QoL at 3 months (P = 0.01).

Conclusions:

Evaluation using the IND-VFQ33 revealed that newly diagnosed glaucoma patients have a significant worsening of QoL after initiation of topical ocular hypotensive therapy. This should be an important consideration when educating patients about the disease and its therapy.

Risk factors for low vision related functioning in the Mycotic Ulcer Treatment Trial: a randomised trial comparing natamycin with voriconazole

BACKGROUND/AIMS

The Mycotic Ulcer Treatment Trial I (MUTT I) was a double-masked, multicentre, randomised controlled trial, which found that topical natamycin is superior to voriconazole for the treatment of filamentous fungal corneal ulcers. In this study, we determine risk factors for low vision-related quality of life in patients with fungal keratitis.

METHODS

The Indian visual function questionnaire (IND-VFQ) was administered to MUTT I study participants at 3 months. Associations between patient and ulcer characteristics and IND-VFQ subscale score were assessed using generalised estimating equations.

RESULTS

323 patients were enrolled in the trial, and 292 (90.4%) completed the IND-VFQ at 3 months. Out of a total possible score of 100, the average VFQ score for all participants was 81.3 (range 0-100, SD 23.6). After correcting for treatment arm, each logMAR line of worse baseline visual acuity in the affected eye resulted in an average 1.2 points decrease on VFQ at 3 months (95% CI -1.8 to 0.6, p<0.001). Those who required therapeutic penetrating keratoplasty had an average of 25.2 points decrease on VFQ after correcting for treatment arm (95% CI -31.8 to -18.5, p<0.001). Study participants who were unemployed had on average 28.5 points decrease on VFQ (95% CI -46.9 to -10.2, p=0.002) after correcting for treatment arm.

CONCLUSIONS

Monocular vision loss from corneal opacity due to fungal keratitis reduced vision-related quality of life. Given the relatively high worldwide burden of corneal opacity, improving treatment outcomes of corneal infections should be a public health priority.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov Identifier: NCT00996736.

Vision-Related Quality-of-Life Outcomes in the Mycotic Ulcer Treatment Trial I: A Randomized Clinical Trial

IMPORTANCE

Given the limitations in health care resources, quality-of-life measures for interventions have gained importance.

OBJECTIVE

To determine whether vision-related quality-of-life outcomes were different between the natamycin and voriconazole treatment arms in the Mycotic Ulcer Treatment Trial I, as measured by an Indian Vision Function Questionnaire.

DESIGN, SETTING, AND PARTICIPANTS

Secondary analysis (performed October 11-25, 2014) of a double-masked, multicenter, randomized, active comparator-controlled, clinical trial at multiple locations of the Aravind Eye Care System in South India that enrolled patients with culture- or smear-positive filamentous fungal corneal ulcers who had a baseline visual acuity of 20/40 to 20/400 (logMAR of 0.3-1.3).

INTERVENTIONS

Study participants were randomly assigned to topical voriconazole, 1%, or topical natamycin, 5%.

MAIN OUTCOMES AND MEASURES

Subscale score on the Indian Vision Function Questionnaire from each of the 4 subscales (mobility, activity limitation, psychosocial impact, and visual function) at 3 months.

RESULTS

A total of 323 patients were enrolled in the trial, and 292 (90.4%) completed the Indian Vision Function Questionnaire at 3 months. The majority of study participants had subscale scores consistent with excellent function. After adjusting for baseline visual acuity and organism, we found that study participants in the natamycin-treated group scored, on average, 4.3 points (95% CI, 0.1-8.5) higher than study participants in the voriconazole-treated group (P = .046). In subgroup analyses looking at ulcers caused by Fusarium species and adjusting for baseline best spectacle-corrected visual acuity, the natamycin-treated group scored 8.4 points (95% CI, 1.9-14.9) higher than the voriconazole-treated group (P = .01). Differences in quality of life were not detected for patients with Aspergillus or other non-Fusarium species as the causative organism (1.5 points [95% CI, -3.9 to 6.9]; P = .52).

CONCLUSIONS AND RELEVANCE

We found evidence of improvement in vision-related quality of life among patients with fungal ulcers who were randomly assigned to natamycin compared with those randomly assigned to voriconazole, and especially among patients with Fusarium species as the causative organism. Incorporation of quality-of-life measures in clinical trials is important to fully evaluate the effect of the studied interventions.

TRIAL REGISTRATION

clinicaltrials.gov Identifier:NCT00996736.

Development of an Elderly Low Vision Quality of Life Questionnaire for less-developed areas of China

PURPOSE

To develop a quality of life questionnaire appropriate for elderly low-vision patients in less-developed areas of China.

METHODS

The study was conducted at the Wenzhou Medical University Affiliated Eye Hospital. In the initial development of the questionnaire, we identified visual function concerns with individual interviews and designed a questionnaire and an empirical assessment of the questionnaire. Each individual visual function concern was then transformed into a question and put into a rating scale from 0 to 4. Then, questionnaire interviews were conducted on 188 low-vision patients and 63 normal control patients for item reduction and evaluation of psychometric properties.

RESULTS

We first identified 24 concerns that older adults with serious vision loss thought most affected their daily lives. The initial item list of the Elderly Low Vision Quality of Life Questionnaire (ELVQoL) consisted of 28 items, including the 24 identified items and 4 additional concerns about general vision. Psychometric item reduction removed 9 items, and a 19-item questionnaire was generated. Assessment showed that the resulting questionnaire had acceptable internal consistency, reliability, and validity (Cronbach's α > 0.9, mean item-total correlations >0.6, test-retest reliability >0.9, and concurrent validity range from 0.6 to 0.9). Low education level, need for a full range of working distances, and retinal diseases were all predictors of reduced visually related quality of life.

CONCLUSIONS

A patient-derived ELVQoL Questionnaire was developed specifically for elderly, uneducated, rural Chinese. All the psychometric properties met accepted levels for a disease-specific Qol Questionnaire.

Functional and visual acuity outcomes of cataract surgery in Timor-Leste (East Timor)

PURPOSE

To report functional outcomes following cataract surgery in Timor-Leste.

METHODS

Pre- and post-intervention study measuring visual function improvement following cataract surgery. Presenting visual acuity (VA) was measured and visual function documented using the Indian vision function questionnaire (IND-VFQ).

RESULTS

All 174 persons undergoing cataract surgery from November 2009 to January 2011 in Timor-Leste were included. Mean age was 65.4 years; 113 (64.9%) were male, 143 (82.1%) were from a rural background and 151 (86.8%) were illiterate. Pre-operatively, 77 of 174 patients (44.3%, 95% confidence interval, CI, 37.0-51.7%) were blind (VA ≤3/60), 77 (44.3%, 95% CI 37.0-51.7%) were visually impaired (VA <6/18->3/60), while 20 (11.5%, 95% CI 7.4-16.9%) had presenting acuity ≥6/18 in the better eye. Following surgery, significant improvement in visual function was demonstrated by an effect size of 2.8, 3.7 and 3.9 in the domains of general functioning, psychosocial impact and visual symptoms, respectively. Four weeks following surgery, 85 patients (48.9%, 95% CI 41.5-66.3%) had a presenting VA ≥6/18, 74 (42.5%, 95% CI 35.3-45.9%) were visually impaired and 15 (8.6%, 95% CI 5.0-13.6%) were blind. IND-VFQ improvement occurred even in patients remaining visually impaired or blind following surgery.

CONCLUSION

In this setting, cataract surgery led to a significant improvement in visual function but the VA results did not meet World Health Organization quality criteria. IND-VFQ results, although complementary to clinical VA outcomes did not, in isolation, reflect the need to improve program quality.

Use of subjective and objective criteria to categorise visual disability

CONTEXT

Visual disability is categorised using objective criteria. Subjective measures are not considered.

AIM

To use subjective criteria along with objective ones to categorise visual disability.

SETTINGS AND DESIGN

Ophthalmology out-patient department; teaching hospital; observational study.

MATERIAL AND METHODS

Consecutive persons aged >25 years, with vision <20/20 (in one or both eyes) due to chronic conditions, like cataract and refractive errors, were categorized into 11 groups of increasing disability; group-zero: normal range of vision, to group-X: no perception of light, bilaterally. Snellen's vision; binocular contrast sensitivity (Pelli-Robson chart); automated binocular visual field (Humphrey; Esterman test); and vision-related quality of life (Indian Visual Function Questionnaire-33; IND-VFQ33) were recorded.

STATISTICAL ANALYSIS

SPSS version-17; Kruskal-wallis test was used to compare contrast sensitivity and visual fields across groups, and Mann-Whitney U test for pair-wise comparison (Bonferroni adjustment; P < 0.01). One-way ANOVA compared quality of life data across groups; for pairwise significance, Dunnett T3 test was applied.

RESULTS

In 226 patients, contrast sensitivity and visual fields were comparable for differing disability grades except when disability was severe (P < 0.001), or moderately severe (P < 0.01). Individual scales of IND-VFQ33 were also mostly comparable; however, global scores showed a distinct pattern, being different for some disability grades but comparable for groups III (78.51 ± 6.86) and IV (82.64 ± 5.80), and groups IV and V (77.23 ± 3.22); these were merged to generate group 345; similarly, global scores were comparable for adjacent groups V and VI (72.53 ± 6.77), VI and VII (74.46 ± 4.32), and VII and VIII (69.12 ± 5.97); these were merged to generate group 5678; thereafter, contrast sensitivity and global and individual IND-VFQ33 scores could differentiate between different grades of disability in the five new groups.

CONCLUSIONS

Subjective criteria made it possible to objectively reclassify visual disability. Visual disability grades could be redefined to accommodate all from zero-100%.

The challenges in improving outcome of cataract surgery in low and middle income countries

Cataract is the leading cause of blindness globally and surgery is the only known measure to deal with it effectively. Providing high quality cataract surgical services is critical if patients with cataract are to have their sight restored. A key focus of surgery is the outcome of the procedure. In cataract surgery this is measured predominantly, using visual acuity. Population- and hospital-based studies have revealed that the visual outcome of cataract surgery in many low and middle income settings is frequently sub-optimal, often failing to reach the recommended standards set by the World Health Organization (WHO). Another way of measuring outcome of cataract surgery is to ask patients for their views on whether surgery has changed the functioning of their eyes and their quality of life. There are different tools available to capture patient views and now, these patient-reported outcomes are becoming more widely used. This paper discusses the visual outcome of cataract surgery and frames the outcome of surgery within the context of the surgical service, suggesting that the process and outcome of care cannot be separated. It also discusses the components of patient-reported outcome tools and describes some available tools in more detail. Finally, it describes a hierarchy of challenges that need to be addressed before a high quality cataract surgical service can be achieved.

The impact of successful cataract surgery on quality of life, household income and social status in South India

Background

To explore the hypothesis that sight restoring cataract surgery provided to impoverished rural communities will improve not only visual acuity and vision-related quality of life (VRQoL) but also poverty and social status.

Methods

Participants were recruited at outreach camps in Tamil Nadu, South India, and underwent free routine manual small incision cataract surgery (SICS) with intra-ocular lens (IOL) implantation, and were followed up one year later. Poverty was measured as monthly household income, being engaged in income generating activities and number of working household members. Social status was measured as rates of re-marriage amongst widowed participants. VRQoL was measured using the IND-VFQ-33. Associations were explored using logistic regression (SPSS 19).

Results

Of the 294 participants, mean age ± standard deviation (SD) 60±8 years, 54% men, only 11% remained vision impaired at follow up (67% at baseline; p<0.001). At one year, more participants were engaged in income generating activities (44.7% to 77.7%; p<0.001) and the proportion of households with a monthly income <1000 Rps. decreased from 50.5% to 20.5% (p<0.05). Overall VRQoL improved (p<0.001). Participants who had successful cataract surgery were less likely to remain in the lower categories of monthly household income (OR 0.05–0.22; p<0.02) and more likely to be engaged in income earning activities one year after surgery (OR 3.28; p = 0.006). Participants widowed at baseline who had successful cataract surgery were less likely to remain widowed at one year (OR 0.02; p = 0.008).

Conclusion

These findings indicate the broad positive impact of sight restoring cataract surgery on the recipients’ as well as their families’ lives. Providing free high quality cataract surgery to marginalized rural communities will not only alleviate avoidable blindness but also - to some extent - poverty in the long run.

Pre-validation methods for developing a patient reported outcome instrument

Background

Measures that reflect patients' assessment of their health are of increasing importance as outcome measures in randomised controlled trials. The methodological approach used in the pre-validation development of new instruments (item generation, item reduction and question formatting) should be robust and transparent. The totality of the content of existing PRO instruments for a specific condition provides a valuable resource (pool of items) that can be utilised to develop new instruments. Such 'top down' approaches are common, but the explicit pre-validation methods are often poorly reported. This paper presents a systematic and generalisable 5-step pre-validation PRO instrument methodology.

Methods

The method is illustrated using the example of the Aberdeen Glaucoma Questionnaire (AGQ). The five steps are: 1) Generation of a pool of items; 2) Item de-duplication (three phases); 3) Item reduction (two phases); 4) Assessment of the remaining items' content coverage against a pre-existing theoretical framework appropriate to the objectives of the instrument and the target population (e.g. ICF); and 5) qualitative exploration of the target populations' views of the new instrument and the items it contains.

Results

The AGQ 'item pool' contained 725 items. Three de-duplication phases resulted in reduction of 91, 225 and 48 items respectively. The item reduction phases discarded 70 items and 208 items respectively. The draft AGQ contained 83 items with good content coverage. The qualitative exploration ('think aloud' study) resulted in removal of a further 15 items and refinement to the wording of others. The resultant draft AGQ contained 68 items.

Conclusions

This study presents a novel methodology for developing a PRO instrument, based on three sources: literature reporting what is important to patient; theoretically coherent framework; and patients' experience of completing the instrument. By systematically accounting for all items dropped after the item generation phase, our method ensures that the AGQ is developed in a transparent, replicable manner and is fit for validation. We recommend this method to enhance the likelihood that new PRO instruments will be appropriate to the research context in which they are used, acceptable to research participants and likely to generate valid data.

Choosing appropriate patient-reported outcomes instrument for glaucoma research: a systematic review of vision instruments

PURPOSE

To identify vision Patient-Reported Outcomes instruments relevant to glaucoma and assess their content validity.

METHODS

MEDLINE, MEDLINE in Process, EMBASE and SCOPUS (to January 2009) were systematically searched. Observational studies or randomised controlled trials, published in English, reporting use of vision instruments in glaucoma studies involving adults were included. In addition, reference lists were scanned to identify additional studies describing development and/or validation to ascertain the final version of the instruments. Instruments' content was then mapped onto a theoretical framework, the World Health Organization International Classification of Functioning, Disability and Health. Two reviewers independently evaluated studies for inclusion and quality assessed instrument content.

RESULTS

Thirty-three instruments were identified. Instruments were categorised into thirteen vision status, two vision disability, one vision satisfaction, five glaucoma status, one glaucoma medication related to health status, five glaucoma medication side effects and six glaucoma medication satisfaction measures according to each instruments' content. The National Eye Institute Visual Function Questionnaire-25, Impact of Vision Impairment and Treatment Satisfaction Survey-Intraocular Pressure had the highest number of positive ratings in the content validity assessment.

CONCLUSION

This study provides a descriptive catalogue of vision-specific PRO instruments, to inform the choice of an appropriate measure of patient-reported outcomes in a glaucoma context.

Visual impairment from cataract and health related quality of life: results from a case-control study in the Philippines

PURPOSE

To evaluate a vision related quality of life (VRQoL) scale, the World Health Organization Prevention of Blindness and Deafness Visual Function-20 (WHO/ PBD VF20) and describe the relationship between visual impairment from cataract and vision related and generic Health Related Quality of Life (HRQoL) in a case-control study of adults aged > or = 50 years in the Philippines.

METHODS

Two hundred and thirty eight population based persons visually impaired from cataract and 163 age- gender- matched controls with normal vision were interviewed using the WHO/PBD VF20 and European Quality of Life (EuroQol) questionnaire (an HRQoL). The WHO/PBD VF20 was evaluated using standard psychometric tests.

RESULTS

The WHO/PBD VF20 had good item acceptability and validity. Cases had significantly poorer VRQoL than controls and worsening Visual Acuity (VA) was associated with worsening VRQoL. The general functioning subscale had good internal consistency. The psychosocial sub-scale had a Cronbach's alpha of 0.61, just below the generally accepted criteria of 0.70. Cases were much more likely than controls to report problems with the Euroqol five descriptive domains (EQ-5D)and had significantly poorer self-rated health.

CONCLUSIONS

The study supports the use of the WHO/PBD VF20 in a Philippine population and highlights the worsening VRQoL associated with cataract vision loss. The poorer generic HRQoL among cases compared to controls indicates an impact of visual impairment on perceived health and well-being, beyond vision-specific experience.

Are blind people more likely to accept free cataract surgery? A study of vision-related quality of life and visual acuity in Kenya

PURPOSE

To determine possible differences in visual acuity, socio-demographic factors and vision-related Quality of Life (QoL) between people accepting and people refusing sponsored cataract surgery.

METHODS

Three hundred and fifty seven local residents with visually impairing cataract, presenting at screening sites in Kwale District, Kenya were clinically assessed and interviewed. The World Health Organization (WHO) QoL-questionnaire WHO/Prevention of Blindness and Deafness Visual Functioning Questionnaire 20 (PBD-VFQ20) was used to determine the vision-related QoL. A standardized questionnaire asked for socio-demographic data and prior cataract surgery in one eye. After interview, patients were offered free surgery. Primary outcome was the mean QoL-score between acceptors and non-acceptors. Secondary outcomes were visual acuity and socio-demographic factors and their contribution to QoL-scores and the decision on acceptance or refusal.

RESULTS

Fifty nine people (16.5%) refused and 298 accepted cataract surgery. Vision-related QoL was poorer in people accepting than in those refusing (mean score 51.54 and 43.12 respectively). People with poor visual acuity were only slightly more likely to accept surgery than people with better vision; the strongest predictors of acceptance were the QoL-score and gender. Men were twice as likely to accept compared to women. Of people who accepted surgery, 73.8% had best eye vision of 20/200 or better.

CONCLUSION

In this population, visual acuity was of limited use to predict a person's decision to accept or refuse cataract surgery. QoL-scores provide further insight into which individuals will agree to surgery and it might be useful to adapt the QoL-questions for field use. Gender inequities remain a matter of concern with men being more likely to get sight-restoring surgery.

Validation of the visual disability questionnaire (VDQ) in India

PURPOSE

To validate visual disability questionnaire (VDQ) in patients with low vision in India, and explore whether the two latent traits "importance" and "difficulty" associated with performance of daily activities are valid and independent constructs.

METHODS

The VDQ consisting of 25 items was administered verbally to 137 subjects with low vision aged 16 to 89 years. Responses for each item were rated for importance and difficulty using a 5-category Likert scale. Rasch analysis was used to estimate interval measures of response ratings.

RESULTS

Subjects could discriminate only three response categories for importance and difficulty. Content validity was demonstrated by good separation indices for importance (4.24 and 2.59 for the item and person parameters, respectively) and difficulty ratings (7.64 and 3.33, respectively). High reliability scores were recorded for importance (0.95 and 0.87) and difficulty ratings (0.98 and 0.92). The most important items were "grooming" (1.15 logits) and "reading newspaper" (0.97 logits). Although "threading a needle" was the least important item (-2.79 logits), it was the most difficult task (3.13 logits). The least difficult item was moving around in familiar places (-2.51 logits). A poor correlation was observed between the item measures (r = -0.19, p = 0.34) and also between person measures (r = 0.18, p = 0.03) of importance and difficulty.

CONCLUSIONS

The VDQ is a valid questionnaire with importance and difficulty ratings found to be independent constructs. This questionnaire could be used to prioritize the goals for rehabilitation intervention in patients with low vision.

Economic Evaluation for Ophthalmologists

PURPOSE

This review will describe the basic concepts of economic evaluation, using examples from the ophthalmic literature. The aim is to provide readers with knowledge about the fundamentals of economic evaluation to enable them to read papers critically, make healthcare funding and planning decisions, and understand the economic evaluation of interventions.

REVIEW

Ophthalmic services are often constrained by a lack of funding, and this is true in both high- and low-income countries. Ophthalmology also competes with other healthcare specialities for funding. Economic evaluation is used to identify the most efficient way of allocating and planning the use of these scarce resources among alternative activities. An economic evaluation is typically conducted by comparing two or more interventions in terms of their effectiveness and their cost. Cost is the value of all resources used in the intervention. Effects, or consequences of the intervention, can be measured in monetary terms, through disease-specific outcomes or using health-related quality of life measures. The four most commonly used types of economic evaluations are cost-minimization analysis, cost-benefit analysis, cost-effectiveness analysis and cost-utility analysis. There are a variety of intended and unintended consequences of a health intervention, and so the consequences of the intervention may be positive or negative. Economic models, such as decision trees and Markov models, calculate effectiveness and costs, taking into account all the consequences of the intervention, including complications. Uncertainties in the parameters of the models can be expressed through sensitivity analyses and confidence intervals.

CONCLUSIONS

Economic evaluation may be used to identify the most efficient way of allocating scarce resources among alternative activities. Its use, if standardized in all areas, can improve the quality of care while enhancing efficiency and thereby enabling more programs to be funded.

A pre- and post-treatment evaluation of vision-related quality of life in uveitis

Aim:

To study the effect of treatment on vision-related quality of life (VR-QOL) in uveitis patients.

Materials and Methods:

Interviewer-administered questionnaire-based evaluation of visual function and VR-QOL in Tamil-speaking adult patients with active uveitis at presentation and follow-up by the same interviewer.

Results:

Ninety-eight patients participated in this study. There was a statistically significant improvement in VR-QOL in all the scales following treatment (P < 0.001). Patients with chronic uveitis showed better improvement upon treatment than patients with acute uveitis. The visual symptoms scale showed moderate gains following treatment (effect size 0.56). Persons with bilateral disease had poorer mean scores compared to those with unilateral disease. Visual acuity was closely correlated with VR-QOL scores.

Conclusion:

The VR-QOL measurement has shown that it is sensitive to demonstrate the problems of patients with uveitis irrespective of their demographic profile. The scores improved significantly in patients with uveitis following treatment and have shown close correlation to visual acuity thus demonstrating that VR-QOL is effective in assessing the response to treatment.

Cataract visual impairment and quality of life in a Kenyan population

AIMS

To evaluate the World Health Organization Prevention of Blindness and Deafness 20-item Visual Functioning Questionnaire (WHO/PBD VF20), a vision-related quality of life scale, and to describe the relationship between cataract visual impairment and vision- and generic health-related quality of life, in people >or=50 years of age in Nakuru district, Kenya.

METHODS

The WHO/PBD VF20 was pilot tested and modified. 196 patients with visual impairment from cataract and 128 population-based controls without visual impairment from cataract were identified through a district-wide survey. Additional cases were identified through case finding. Vision- and health-related quality of life were assessed using the WHO/PBD VF20 scale and EuroQol generic health index (European Quality of Life Questionnaire (EQ-5D)), respectively. WHO/PBD VF20 was evaluated using standard psychometric tests, including factor analysis to determine item grouping for summary scores.

RESULTS

The modified WHO/PBD VF20 demonstrated good psychometric properties. Two subscales (general functioning and psychosocial) and one overall eyesight-rating item were appropriate for these data. Increased severity of visual impairment in cases was associated with worsening general functioning, psychosocial and overall eyesight scores (p for trend <0.001). Cases were more likely to report problems with EQ-5D descriptive dimensions than controls (p<0.001), and, among cases, increased severity of visual impairment was associated with worsening self-rated health score.

CONCLUSION

The modified WHO/PBD VF20 is a valid and reliable scale to assess vision-related quality of life associated with cataract visual impairment in this Kenyan population. The association between health-related quality of life and visual impairment reflects the wider implications of cataract for health and well-being, beyond visual acuity alone.