Vision-Related Quality of Life among Patients with Different Types of Age-Related Macular Degeneration

BACKGROUND

This study aimed to assess the vision-related quality of life (VRQol) of patients with age-related macular degeneration (AMD) and to evaluate VRQol according to different types of AMD.

METHODS

In this small-scale, single-center, prospective investigation, patients with AMD and subjects without any signs of macular disease were asked to complete the NEI-VFQ-39. A total of 159 subjects were included and grouped according to the type of AMD as follows: 40 patients with dry AMD in both eyes (DD), 40 patients with exudative AMD in one eye (DE), 41 patients with exudative AMD in both eyes (EE), and 38 subjects without any signs of macular disease, as a control group (CG).

RESULTS

The average age of the participants was 76 ± 7 years, and 44% were male. Most participants were retired (22.4%), and 75% of patients were initially diagnosed by their ophthalmologist. All the AMD groups had significantly worse overall VRQol than the CG. For general vision, near vision, mental health, and role difficulties, all the AMD groups had significantly lower scores than the CG. For distance vision, color vision, peripheral vision, driving difficulties, dependency, and social functioning, only patients in the EE and DE groups had significantly worse scores than the CG. The type of retinal fluid in patients with exudative AMD had no effect on overall VRQol; however, we found that the presence of pigment epithelial detachment could be associated with more role difficulties, such as completing work or working long hours.

CONCLUSION

All types of AMD had a negative effect on vision-related quality of life. This effect was significantly more pronounced in patients with exudative AMD in at least one eye. However, the type of retinal fluid in patients with exudative AMD had no influence on their overall vision-related quality of life.

The Impact of Adult Uveitis on Quality of Life: An Exploratory Study

PURPOSE: This exploratory qualitative research was conducted to understand the quality of life (QoL) impacts of adult uveitis to develop a uveitis QoL item bank, and we present here the results of qualitative analysis of uveitis patient experience.METHODS: A qualitative approach with phenomenological study design was employed to explore the common QoL domains in uveitis. Data were collected using focus groups and face-to-face interviews. The sessions were audio-recorded, transcribed verbatim, and analysed thematically. NViVo software was used to perform qualitative analysis.RESULTS: Eight focus groups and 10 interviews were conducted with 41 patients with uveitis. Seven QoL domains were identified, namely symptoms, emotional, activity limitation, health concerns, convenience, social, and economic impact. Although these QoL domains have been previously identified in other eye diseases, the sub-themes within each QoL domain were unique to uveitis. Participants described a variety of symptoms including increased light sensitivity, blurred vision, pain, redness, and tearing. Participants repeatedly described feeling frustrated due to prognostic uncertainty and associated discomfort. Participants were concerned about the frequent relapses of inflammation, as well as side-effects from long-term systemic medications. Uveitis affected their ability to perform daily tasks such as using computers, driving, and reading books. Direct financial impacts included reduced work hours and the costs of treatment and specialist care.CONCLUSION: Participants with uveitis experience many symptoms in addition to medication-related inconveniences and activity limitations. The QoL issues identified will be used to develop a uveitis-specific QoL item bank.

Visual Impairment and Mental Health: Unmet Needs and Treatment Options

Purpose

An estimated 2.2 billion people are visually impaired worldwide. Given that age-related vision loss is a primary cause of vision impairment, this number is projected to rise with increases in average lifespan. Vision loss often results in significant disability and is associated with a substantial economic burden, reduced quality-of-life, concurrent medical issues, and mental health problems. In this review, the mental health needs of people with vision impairment are examined.

Patients and methods

A review of recent literature on mental health outcomes and current treatments in people with visual impairment was conducted.

Results

Considerable data indicate that rates of depression and anxiety are elevated among people with visual impairments. Moreover, individuals of lower socioeconomic status may be at increased risk for vision impairment and subsequent mental health problems. Existing psychosocial interventions for improving mental health in people with visual impairment show some promise, but are limited by low adherence and lack generalizability.

Conclusion

In order to improve outcomes, a better understanding of the mechanisms linking visual impairment and poor mental health is needed. It will also be essential to develop more effective interventions and expand access to services to improve the detection and treatment of mental health problems in this population.

The patients' view: age-related macular degeneration and its effects - a meta-synthesis

Aim: The aim of this meta-synthesis is to find out what it means for patients with age-related macular degeneration to live with visual impairment, how they cope with the illness and how they experience their medical care, including vascular endothelial growth factor inhibitor therapy.Method: Inclusion criteria: qualitative studies exploring patients' experiences with age-related macular degeneration in their daily lives and with medical care, published in journals in English or German. The included studies were analysed following the rules and principles of grounded theory.Results: For the analysis, twenty-four articles matching the inclusion criteria were identified. Three main analytic themes emerged from the included studies: (i) a life shaped by losses; (ii) the burden of medical treatment; and (iii) coping with vision loss. For patients, visual impairment/vision loss means living with multiple losses in various domains of life. With the introduction of vascular endothelial growth factor inhibitor therapy, patients with neovascular age-related macular degeneration have a good chance of slowing down the disease progression; therapy does, however, also represent a major burden.Conclusion: New strategies need to be conceived to reduce the burden of medical treatment and to improve the dissemination of information about age-related macular degeneration.IMPLICATIONS FOR REHABILITATIONMost of the people with age- related macular degeneration seem to adapt to visual impairment.Medical treatment implies a great physical and psychological burden for patients with neovascular (wet) age- related macular degeneration.The physical and psychological burden needs to be recognized and addressed in the management of patients with neovascular (wet) AMD in medical facilities.More research is needed on how rehabilitation services may support the adaptation process of patients in the different stages of AMD.

'You've got dry macular degeneration, end of story': a qualitative study into the experience of living with non-neovascular age-related macular degeneration

BACKGROUND/OBJECTIVES

To investigate the impact of non-neovascular (dry) age-related macular degeneration (AMD) on the person with respect to diagnosis, vision loss and coping strategies.

SUBJECTS/METHODS

Volunteers with dry AMD with a range of disease severity were given an eye examination and asked to describe aspects of their experience with dry AMD in a semi-structured interview. Interviews were audio-recorded, transcribed, and subjected to Framework analysis. Overarching themes were pre-defined, whilst subthemes were derived from the data.

RESULTS

Twenty-seven participants (81% female), with early (n = 3), intermediate (n = 16) and advanced dry AMD (GA; n = 8) were interviewed. Median (interquartile range) age (years), logMAR binocular visual acuity and Pelli-Robson contrast sensitivity were 76 (71, 80), 0.2 (0.18, 0.40) and 1.65 (1.35, 1.93), respectively. Overarching themes (and subthemes) were: diagnosis (relationship with healthcare professional, psychological impact of diagnosis, and knowledge of AMD, both pre- and post-diagnosis), impact of visual loss (functional and psychological) and coping strategies (help from others and personal strategies). Many participants reported feelings of distress at the time of diagnosis and, particularly noteworthy, several reported a constant fear of their condition worsening.

CONCLUSIONS

Dry AMD, for which there is currently no treatment, can have a significant impact on individuals, even in its early stages, before significant functional vision loss is manifest, as well as in its intermediate and advanced stages. Results from this study offer important insight into the experience of living with dry AMD not previously explored. Moreover, the results have the potential to serve as an educational resource for eyecare professionals.

Identification and Evaluation of Items for Vitreoretinal Diseases Quality of Life Item Banks

Purpose: We are developing item banks assessing the impact of retinal and vitreoretinal diseases (excluding age-related macular degeneration, diabetic retinopathy, and retinal detachment, covered elsewhere) on quality of life (QoL) for adults. This study outlines the first two phases of the multi-stage process: content development and item evaluation.Methods: We grouped retinal and vitreoretinal diseases into hereditary and acquired. Development of the item banks involved two phases: item identification and item evaluation. The items were extracted from three sources: (1) 17 pre-existing PRO instruments, (2) 4 qualitative studies and (3) 79 semi-structured interviews. Item evaluation involved three stages namely, binning (grouping) and winnowing (reduction), expert panel opinion and cognitive interviews.Results: The item identification phase yielded 1,217 items. After three sessions of binning and winnowing, items were reduced to a minimally representative set (n = 411) across nine QoL domains namely, activity limitation, emotional, social, health concerns, symptoms, economic, mobility, convenience, and coping. The hereditary group had a total of 345 items and the acquired group had a total of 257 items. After 23 cognitive interviews items were amended for hereditary diseases resulting in a final set of 345 items and 3 items were amended for acquired diseases, resulting in a final set of 254 items. Overall across nine domains 189 items were common to hereditary and acquired retinal and vitreoretinal diseases.Conclusion: As most of the items were unique to hereditary versus acquired retinal and vitreoretinal disease groups separate item banks are required to capture the QoL impacts for hereditary and acquired retinal and vitreoretinal diseases.

Adaptations to support occupational engagement with age-related vision loss: A metasynthesis study

BACKGROUND.

Age-related vision loss (ARVL) is a progressive process that adversely affects older adults' occupational engagement. As such, older adults often employ a variety of psychological adaptation strategies.

PURPOSE.

The purpose of this study was to identify those psychological adaptation strategies employed by older adults aging with ARVL.

METHOD.

This metasynthesis searched and identified 21 qualitative articles that described a link between psychological adaptation strategies and occupational engagement.

FINDINGS.

The psychological strategies identified were categorized into five themes. The strategies of persisting with hope, positivity, and acceptance and portraying a self-image consistent with independence, competence, and self-reliance were well established in the literature, while other themes were more emerging, such as using humour, relying on religious/spiritual beliefs, and comparing the self to others.

IMPLICATIONS.

By understanding the psychological adaptation strategies employed by older adults with ARVL, occupational therapists will be better positioned to guide their clients toward positive adaptive patterns.

Understanding quality of life impact in people with retinal vein occlusion: a qualitative inquiry

BACKGROUND

Although being the second most common sight-threatening retinal vascular disease after diabetic retinopathy, the patient-centred impact of retinal vein occlusion has not been well studied. This study aims to understand the quality of life issues in people with retinal vein occlusion using a qualitative methodology.

METHODS

In-depth semi-structured interviews were conducted with 17 patients with retinal vein occlusion. All the interviews were digitally recorded and transcribed verbatim. An inductive analytic approach based on the constant comparative method was used for coding, aggregation, and theme development. The qualitative analysis was done using the software NVivo.

RESULTS

Participants had a median age of 73 years (range 34-85 years; females, 71 per cent). Six quality of life themes were identified: concerns about the disease progression and treatment outcome (health concerns), emotional responses to the disease (emotional), experiencing a range of symptoms (symptoms), inability to do things as before (activity limitation), adapting to the visual loss (coping), and inconveniences due to the eye condition (convenience). Participants often felt that lasers and injections did not improve their vision. They feared that their eye condition may come back, or the other eye may be affected. They experienced a range of visual symptoms that affected their day-to-day performance, particularly reading small print, and driving at night. Having multiple treatments and frequent eye appointments were major sources of inconvenience. Patients adopted several coping strategies to manage the stress associated with visual loss.

CONCLUSIONS

This study shows that several aspects of quality of life are compromised in people with retinal vein occlusion. The findings of this study will be used to identify the item content for a vitreoretinal disease-specific quality of life item bank.

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

Aims

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

Method

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

Results

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

Conclusion

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

Exploring the quality of life issues in people with retinal diseases: a qualitative study

Background

The lack of an appropriate retina-specific patient-reported outcome instrument restricts the understanding of the full impact of hereditary retinal diseases and other less common but potentially blinding acquired retinal diseases such as, vascular occlusions, epiretinal membrane, macular hole, central serous retinopathy and other vitreoretinopathies on quality of life. This study aims to explore the quality of life issues in people with hereditary retinal diseases and acquired retinal diseases to develop disease-specific patient-reported outcome instruments.

Methods

A qualitative research methodology to understand the lived experiences of people with retinal diseases was carried out. Data were collected through semistructured interviews. The coding, aggregation and theme development was carried out using the NVivo −10 software.

Results

Seventy-nine interviews were conducted with participants with hereditary retinal diseases (n = 32; median age = 57 years) and acquired retinal diseases (n = 47; median age = 73 years). We identified nine quality of life themes (domains) relevant to people with retinal diseases. Difficulty in performing important day-to-day activities (activity limitation) was the most prominent quality of life issue in the hereditary retinal diseases group whereas concerns about health, disease outcome and personal safety (health concerns) was the most prominent quality of life issue in the acquired retinal diseases group. Participants with hereditary retinal diseases had more issues with social interaction (social well-being), problems with mobility and orientation (mobility), and effect on work and finance (economic) than participants with acquired retinal diseases. On the contrary, participants with acquired retinal diseases reported more inconveniences (conveniences) than participants with hereditary retinal diseases, which were mostly attributed to treatment. Participants with hereditary retinal diseases were coping better compared to participants with acquired retinal diseases.

Conclusions

Our study found that participants with both hereditary and acquired retinal diseases are living with myriad of disease-specific quality of life issues. Many of these issues are completely different and unique to each disease group. Hence, these group of diseases would need separate patient-reported outcome instruments to capture the disease-specific quality of life impacts.

Electronic supplementary material

The online version of this article (10.1186/s41687-017-0023-4) contains supplementary material, which is available to authorized users.

Visual impairment, coping strategies and impact on daily life: a qualitative study among working-age UK ex-service personnel

Background

Sustaining a visual impairment may have a substantial impact on various life domains such as work, interpersonal relations, mobility and social and mental well-being. How to adjust to the loss of vision and its consequences might be a challenge for the visually impaired person. The purpose of the current study was to explore how younger male ex-Service personnel cope with becoming visually impaired and how this affects their daily life.

Methods

Semi-structured interviews with 30 visually impaired male ex-Service personnel, all under the age of 55, were conducted. All participants are members of the charity organisation Blind Veterans UK. Interviews were analysed thematically.

Results

Younger ex-Service personnel applied a number of different strategies to overcome their loss of vision and its associated consequences. Coping strategies varied from learning new skills, goal setting, integrating the use of low vision aids in their daily routine, to social withdrawal and substance misuse. Vision loss affected on all aspects of daily life and ex-Service personnel experienced an on-going struggle to accept and adjust to becoming visually impaired.

Conclusions

Health care professionals, family and friends of the person with the visual impairment need to be aware that coping with a visual impairment is a continuous struggle; even after a considerable amount of time has passed, needs for emotional, social, practical and physical support may still be present.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2455-1) contains supplementary material, which is available to authorized users.

Teleretinal imaging for detection of referable macular degeneration

PURPOSE

The purpose of this study was to determine the sensitivity and specificity for detection of referable age-related macular degeneration (AMD) using an existing nonmydriatic telemedicine pathway for diabetic retinopathy screening with comparison to same-day face-to-face examination by a retina specialist.

METHODS

Subjects in this study underwent nonmydriatic and mydriatic digital retinal imaging on the same day as stereoscopic dilated examination of the macula by a retina specialist and the level of AMD was recorded for each eye. Images were graded by two trained readers as nonreferable or referable (AREDS [Age-Related Eye Disease Study] grading of level 3 or greater). Sensitivity and specificity were calculated by comparing referral recommendations between each reader and the retina specialist ("gold standard").

RESULTS

There were 47 subjects (94 eyes) enrolled in the study. Sensitivity for nonreferable AMD with nonmydriatic imaging was 1.0 (reader 1) and 1.0 (reader 2), whereas specificity was 0.75 (reader 1) and 0.91 (reader 2). Sensitivity for referable AMD with nonmydriatic imaging was 0.84 (reader 1) and 0.88 (reader 2), whereas specificity was 0.81 (reader 1) and 0.81 (reader 2).

CONCLUSIONS

Our study showed that nonmydriatic digital retinal imaging had excellent sensitivity and specificity in identifying referable and nonreferable AMD using an existing validated telemedicine pathway for diabetic retinopathy screening.

Vision for improvement: Expressive writing as an intervention for people with Stargardt's disease, a rare eye disease

This study implemented and evaluated the effectiveness of an expressive writing intervention among patients with Stargardt's disease, a rare disease due to macular degeneration. Participants were randomly assigned to either an expressive writing intervention or a neutral writing condition. Participants completed measures at three time points: baseline, 3 weeks, and 6 weeks post-intervention. Psychological health outcomes improved at the 3-week follow-up for the intervention condition compared to control. Self-reported physical health improved at the 6-week follow-up in the intervention condition compared to control. These results suggest that expressive writing may be an effective, practical, and low-cost intervention for those with Stargardt's disease.

Worry in adolescents with visual impairment

We assessed worries of 162 German adolescents with visual impairment. Most adolescents reported low levels of worry. Nonetheless, about 25% showed moderate to high levels of worry related to a further decline of vision and not finding the right romantic partner. While adolescents with visual impairment reported lower levels of worry than an age- and gender-matched sample of sighted adolescents, adolescents with stronger visual impairment worried more than those with lower levels of visual impairment. In addition, higher levels of worry were associated with more depressive symptoms and, in part, with less optimism, negative changes of vision in recent years, higher age, and worse grades at school. Possible reasons for the inconsistent associations of visual impairment with levels of worry are discussed.

Factors That Influence the Occupational Engagement of Older Adults with Low Vision: A Scoping Review

Introduction:

Prior research has provided occupational therapists with an understanding of the negative impact of low vision on self care, leisure and productivity. In order to guide future low-vision rehabilitation services, an understanding of the factors that influence the occupational engagement of older adults with age-related vision loss (ARVL) is also needed.

Method:

A scoping review of the literature was conducted in order to identify those factors that have been shown to influence the occupational engagement of older adults with ARVL, and to identify future research needs.

Findings:

As identified in this scoping review, five types of factors were shown to influence occupational engagement for older adults with ARVL including: demographic variables, emotional components, behavioural components, diagnostic components, and environmental aspects.

Conclusion:

Although findings pertaining to personal factors can inform practice, few studies explored the influence of environmental factors on occupational engagement. Given that occupation is a result of person-environment transactions, it is important that future research more fully explores environmental influences in order to enable occupational therapists to deliver services that optimize the occupational performance of seniors with ARVL.

Living with Fear: The Lived Experience of Community Mobility among Older Adults with Low Vision

This secondary analysis of data drawn from a descriptive phenomenological study explored how older adults with low vision experience and manage community mobility. Participants included 34 urban and rural older adults, age 70 years and older, who were not using low-vision-rehabilitation services. The findings convey a core element of the experience of community mobility for participants: living with a pervasive sense of fear regarding one’s body and way of being. Participants continually gauged risks associated with mobility and engaged in risk avoidance and management strategies. Community mobility was often restricted by participants because of perceived risks, leading to reduced participation in a range of physical, social, and other types of activities. Further research on environmental factors mediating community mobility and on strategies effective in maintaining mobility among seniors with low vision is essential to optimize participation, health, and service delivery.

Self-management programs for adults with low vision: needs and challenges

OBJECTIVE

To explore the needs of individuals with low vision in order to inform the contents of a low vision self-management (SM) program and determine potential barriers to participation.

METHODS

Semi-structured interviews were conducted with 48 participants with low vision resulting different from eye conditions. Qualitative analysis was conducted in order to identify major themes.

RESULTS

All participants described a range of consequences as a result of vision loss including difficulties with functional activities, social interaction and emotional distress. Less than half were interested in attending a SM program. Barriers included practical reasons as well as a perceived lack of need and unclear or negative perceptions of such a program.

CONCLUSION

SM programs for low vision are a promising way to help address the range of difficulties experienced by this population if barriers to participation can be overcome.

PRACTICE IMPLICATIONS

SM programs should include vision-specific strategies, training in generic problem-solving and goal setting skills and how to cope with emotional reactions to vision impairment. Programs should be delivered and promoted in such a way to enhance access and encourage uptake by those with a range of vision loss in the community.

Quality of life in age-related macular degeneration: a review of the literature

BACKGROUND

The Age-related Macular Degeneration Alliance International commissioned a review of the literature on quality of life (QoL) in macular degeneration (MD) with a view to increasing awareness of MD, reducing its impact and improving services for people with MD worldwide.

METHOD

A systematic review was conducted using electronic databases, conference proceedings and key journal hand search checks. The resulting 'White Paper' was posted on the AMD Alliance website and is reproduced here.

REVIEW

MD is a chronic, largely untreatable eye condition which leads to loss of central vision needed for tasks such as reading, watching TV, driving, recognising faces. It is the most common cause of blindness in the Western world. Shock of diagnosis, coupled with lack of information and support are a common experience. Incidence of depression is twice that found in the community-dwelling elderly, fuelled by functional decline and loss of leisure activities. Some people feel suicidal. MD threatens independence, especially when comorbidity exacerbates functional limitations. Rehabilitation, including low vision aid (LVA) provision and training, peer support and education, can improve functional and psychological outcomes but many people do not receive services likely to benefit them. Medical treatments, suitable for only a small minority of people with MD, can improve vision but most limit progress of MD, at least for a time, rather than cure. The White Paper considers difficulties associated with inappropriate use of health status measures and misinterpretation of utility values as QoL measures: evidence suggests they have poor validity in MD.

CONCLUSION

There is considerable evidence for the major damage done to QoL by MD which is underestimated by health status and utility measures. Medical treatments are limited to a small proportion of people. However, much can be done to improve QoL by early diagnosis of MD with good communication of prognosis and continuing support. Support could include provision of LVAs, peer support, education and effective help in adjusting to MD. It is vital that appropriate measures of visual function and QoL be used in building a sound evidence base for the effectiveness of rehabilitation and treatment.