Rasch analysis of three dry eye questionnaires and correlates with objective clinical tests

Spanish Cross-Cultural Adaptation, Rasch Analysis and Validation of the Ocular Comfort Index (OCI) Questionnaire

The Ocular Comfort Index (OCI) assesses ocular surface irritation and grades the severity of dry eye disease. This study sought to adapt the OCI questionnaire into Spanish, and then to assess the psychometric performance and validity of the new adapted version (OCI-versión española, OCI_VE). The questionnaire was translated, back translated, and then cross-culturally adapted for use with Spanish-speaking individuals. The OCI_VE was completed by 450 participants, including 53 subjects that were diagnosed with dry eye disease. Through a Rasch analysis, the psychometric properties of item fit, targeting, person separation, reliability, and differential item functioning (DIF) were assessed. To test the convergent validity, we examined the correlation between the OCI_VE and the Computer Vision Symptom Scale (CVSS17). Validity was tested in a subgroup of participants with and without dry eye, and test-retest repeatability was determined in a subset of 151 individuals. We also compared, via DIF, the performance of the OCI_VE with that of the original OCI. Our Rasch analysis revealed a good model fit, high accuracy, good targeting, unidimensionality, and no DIF according to gender. The validity and repeatability were good. The OCI_VE shows comparable psychometric properties to the original English version, making it a valid tool for measuring dry eye symptoms in Spanish adults.

Outcome Measures to Assess Dry Eye Severity: A Review

Outcome measures used to assess efficacy of dry eye therapeutics have not been consistently applied in clinical settings, nor have they been shown to correlate with functional outcomes. We propose that corneal staining, a clinically meaningful dry eye parameter, should be used as a standard objective outcome measure across all clinical trials evaluating dry eye treatments. We justify this based on evidence regarding its relationship to vision and vision related quality-of-life. In addition, corneal staining has been shown to correlate with ocular surface inflammation, a well elucidated aspect of dry eye pathophysiology and an active area in therapeutics research. No one outcome measure explored herein correlates perfectly to this heterogenous disease. However, there is mounting evidence showing the correlation between corneal staining and functional visual indices. We hope that future clinical trials will standardize corneal staining as a measure to determine the efficacy of interventions and justify their clinical utility.

Dry Eye Disease Among Mongolian and Han Older Adults in Grasslands of Northern China: Prevalence, Associated Factors, and Vision-Related Quality of Life

Purpose: Dry eye disease (DED) is projected to have increasing public health burden in China with the aging population. No published studies on the epidemiology of DED have been found in grasslands. We estimated DED prevalence among older adults living in grasslands of northern China and investigated its associated factors and impact on vision-related quality of life (VR-QoL). Methods: A multistage cluster random sampling technique was used to select Mongolian and Han participants aged over 40 from November 2020 to May 2021 in this area. An assessment of DED was performed with Ocular Surface Disease Index (OSDI) questionnaire, Schirmer's I test (ST), and Tear film break up time (TBUT). All the participants completed the Chinese version of National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) assessing VR-QoL. Results: Of the 1,400 enumerated residents, 1,287 were examined. The overall age and gender standardized prevalence of DED was 34.5%, of which, 32.6% of Mongolian and 35.4% of Han had DED. In a multivariate model, statistically significant associations were found with advancing age [odds ratio (OR) 1.03, 95% confidence interval (CI) 1.02-1.04], female gender (OR 1.32, 95% CI 1.04-1.68), smoking (OR 0.7, 95% CI 0.5-0.98), anti-fatigue eye-drop use (OR 0.56, 95% CI 0.41-0.77), milk product intake (OR 0.55, 95% CI 0.39-0.77), number of household members (OR 0.8, 95% CI 0.72-0.88). DED was associated with lower scores on VR-QoL (β= -0.14, P < 0.01). Similar results were observed when analyses were stratified by ethnicity. Conclusions: The novelty-associated factors for DED in the grasslands area were anti-fatigue eye drop use, milk product intake, and number of household members. DED and its components were associated with VR-QoL. Further prospective studies are needed to confirm these findings.

Vision-related quality of life with myopia management: A review

The disease of myopia has come into focus as a worldwide public health concern. Myopia has shown increasing prevalence, incidence at earlier age and progression to a higher degree. Progressive increase in degree of myopia is strongly associated with increase in axial length of the eye. Various interventions have been shown to slow axial elongation in children. These interventions have been studied to assess efficacy in slowing axial elongation and correction of vision. In addition, research into quality of vision, risk of adverse events, overall safety and impact on vision-related quality (VR-QoL) of life has been pursued. In contrast, studies have been published to demonstrate the risks of myopia, high myopia and increased axial length. This review will discuss VR-QoL assessment on the most effective and most commonly prescribed interventions to slow axial elongation and myopia progression. The patient attributes considered are VR-QoL scores from validated instruments. The development and use of validated survey instruments to assess the patient-reported outcomes is discussed. The review demonstrates that there are numerous factors that may impact VR-QoL to evaluate in the decision-making process when eye care providers consider when, how and if to prescribe myopia management (MM) for children with myopia.

Reexamining Ophthalmic Drugs, Safety and Tolerability in Phase 1 Clinical Trials

Purpose

The purpose of this study was to evaluate the safety and tolerability profile of drugs used for treating common eye disorders when applied to normal healthy volunteers (NHVs) as explored in phase 1 trials.

Subjects and Methods

A total of 166 NHVs were identified in six phase 1 trials, examined in a retrospective analysis. The primary endpoints were visual comfort (by ocular comfort index, OCI) and safety (laboratory evaluations, vital signs (VS), visual acuity (VA), intraocular pressure (IOP), lissamine green and fluorescein staining, conjunctival hyperemia, chemosis, and adverse events’ incidence (AE)).

Results

Compared to baseline, 75.9%, 40.4% and 73.7% of NHV (for lubricant, hypotensive and antibiotic treatments, respectively) improved their OCI score by their final visit. Laboratory evaluations and VS were within normal ranges in 88% of NHV. Similar results were found for VA, corneal and conjunctival staining, and chemosis. IOP decreased significantly in the hypotensive agents’ group, trace to mild hyperemia was reported in 32.1%, 27.1%, and 6.8%, respectively. Additionally, lubricant and hypotensive investigational drugs (ID) had a lower risk of incidence of AE than approved drugs (OR 0.856, 95% CI [0.365, 1.999] and 0.636, 95% CI [0.096, 4.197], respectively). Meanwhile, on antibiotic drugs, the risk for ID-related AE was higher (OR 1.313, 95% CI [0.309, 5.583]).

Conclusion

Phase 1 trials are important in order to ensure the safety and tolerability of ophthalmic medications. This study demonstrates that NHVs do not face a significant risk of harm in these studies, since 98% of the reported AE were mild, and all AE were resolved by the end of the study in which they appeared.

Trial Registration

This is a retrospective study of six previously conducted clinical trials, registered on clinicaltrials.gov with the following registration IDs: NCT04081610, NCT03524157, NCT03520348, NCT03966365, NCT03965052 and, NCT03519516.

Validation of the Arabic version of the Ocular Surface Disease Index Questionnaire

AIM

To develop an Arabic version of the ocular surface disease index (OSDI) and to assess its reliability and validity.

METHODS

A cross sectional study was carried out to validate the Arabic version of the OSDI questionnaire. Initially, forward-backward translation was used to translate the English version of OSDI into Arabic. The translated questionnaire was tested for equivalence and cultural adaptability. Totally 200 subjects were then recruited from a non-clinical population and asked to complete the Arabic version of the OSDI (ARB-OSDI). The reliability of the questionnaire was assessed using Cronbach's-α. A subgroup of 30 participants was asked to complete the questionnaire on two occasions to test the test-retest reliability.

RESULTS

A total of 200 participants were enrolled in the study. The average age of the study participants was 31.21±13.2y and 57% were male. An acceptable internal consistency level for the ARB-OSDI questionnaire measured by Cronbach's-α was revealed. All questions showed good internal consistency. Test-retest reliability analysis revealed good stability (interclass correlation coefficient, r=0.832, P<0.001). The construct validity for the questionnaire was also high.

CONCLUSION

The ARB-OSDI questionnaire shows very good psychometric properties (acceptable internal consistency and test-retest reliability). That makes the questionnaire a valid potential tool to use in Arabic-speaking countries to monitor symptoms of dry eye disease in a larger population.

Characterization and Prediction of the Clinical Outcome of Intense Pulsed Light-Based Treatment in Dry Eye Associated to Meibomian Gland Dysfunction

This non-comparative prospective case series was conducted to characterize the clinical impact of intense pulsed light (IPL)-based treatment in dry eyes associated to Meibomian gland dysfunction (MGD), defining the predicting factors for a successful outcome with this therapy in a large case series. A total of 390 eyes (195 patients, range: 23–93 years) received four sessions of Optima IPL system (Lumenis, Yokneam, Israel). Significant changes were observed in tear film osmolarity in both eyes (p < 0.001) and in meibum quality (p < 0.001), with more eyes showing clear or yellow secretions after therapy. Mean change in the ocular surface disease index (OSDI) was −8.61, ranging from −27.00 to 11.00. This change was significantly correlated with the baseline value of OSDI (r = −0.489, p < 0.001). The change in osmolarity correlated significantly with the baseline osmolarity in both eyes (right r = −0.636, left r = −0.620, p < 0.001). A linear predicting model of the change in OSDI with therapy was obtained: change OSDI = 10.99 − 0.35 × OSDI − 1.03 × NIBUT_RE-LE (mean non-invasive break up time of right and left eye) − 2.03 × Meibum quality grade (p = 0.001; R²: 0.325). In conclusion, the improvement in symptomatology achieved with an IPL-based therapy can be predicted at baseline using a linear model considering the level of MGD and the magnitude of OSDI and NIBUT (non-invasive break-up time).

Assessment of four validated questionnaires for screening of dry eye disease in an African cohort

PURPOSE

To evaluate the 5-item dry eye questionnaire (DEQ-5) for measurement precision and unidimensionality, and assess the ability of Ocular Surface Disease Index (OSDI), McMonnies Dry Eye Questionnaire (MQ), Ocular Comfort Index questionnaires (OCI), and DEQ to predict clinical measures of DED in an African population.

METHOD

Participants (n = 113; mean age 24.7 ± 5.4 years) completed all four questionnaires administered in a randomized order. Internal consistency and test-retest reliability of the instruments were assessed. A masked examiner performed clinical dry eye tests in both eyes of participants and the results used to classify into either "dry" or "non-dry" groups. The diagnostic criteria for dry eye disease were tear break up time (TBUT) < 10 s plus at least one of Schirmer <15 mm in 5 min., > 5 corneal staining spot, or > 9 conjunctival staining spots. Rasch analysis was performed to assess the DEQ for unidimensionality and measurement precision, and receiver operating characteristic curve (AUC) analysis was used to assess the ability of the four questionnaires to predict clinical measures of DED.

RESULTS

The responses from the DEQ-5 met the Rasch analysis criterion of unidimensionality with infit and outfit values of between 0.74-1.43 mean-square and 0.69-1.49 mean-square, respectively, and measurement precision of 2.33. Internal consistency and test-retest reliability of each test was high, with Cronbach alpha >0.70 for the questionnaire and their respective subscales but internal consistency reliability of the MQ was poor (Cronbach's alpha = 0 .29-0 0.52). Each test segregated the "dry" and "non-dry" groups with moderate (all AUC 0.70-0.80) and similar accuracy (P > .05).

CONCLUSION

The DEQ -5 demonstrated adequate measurement precision and unidimensionality. Each of the four questionnaires showed psychometric validity for clinical use in the African population, and modest and similar accuracy when screening for dry eye signs but the performance of the McMonnies questionnaire was limited in terms of internal consistency reliability.

Function and Morphology of the Meibomian Glands Using a LipiView Interferometer in Rotating Shift Medical Staff

Purpose

To investigate the function and morphology of meibomian glands (MG) in night shift medical staff (MS).

Methods

Sixty-two eyes of 31 patients in the MS group and 59 eyes of 31 patients in the control group were consecutively enrolled. All participants completed Ocular Surface Disease Index (OSDI) and Standard Patient Dry Eye Evaluation (SPEED) questionnaires for dry eye severity, as well as Schirmer I and tear break-up time (TBUT) tests. LipiView® II Ocular Surface Interferometer was used for lipid layer thickness (LLT), MG dropout, and partial blink (PB) rate tests. MG expression was measured with an MG evaluator.

Results

The OSDI score in the MS group was 22.39 ± 13.42, which was significantly higher than that in the control group (9.87 ± 6.64 Z = −3.997, P=0.001). The SPEED score in the MS group was 7.94 ± 3.81, which was significantly higher than in the control group (3.65 ± 2.11, Z = −4.766, P=0.001). There was no significant difference in Schirmer I test between the MS group and control group (Z = −1.346, P=0.178). TBUT in MS group was significantly shorter than that in the control group (Z = −5.201, P=0.001). The mean LLT of the MS group was 55.02 ± 21.17 nm significantly thinner than that of the control group 72.76 ± 21.62 nm (Z = −4.482, P=0.001). MG loss occurred in 45.16% of affected eyes in the MS group and 16.13% of affected eyes in the control group, and the difference was statistically significant (χ² = 14.352, P=0.001). MG yielding liquid secretion and MG yielding secretion score were significantly lower in the MS group than in the control group (Z = −3.641, P=0.001; Z = −3.146, P=0.001, resp.). There was a negative correlation between mean LLT and SPEED score (Spearman r = −0.363, P=0.045).

Conclusions

Night shift MS had a higher incidence of MGD compared to day workers.

Evaluation of ocular symptoms and tropism of SARS-CoV-2 in patients confirmed with COVID-19

PURPOSE

The SARS-CoV-2 RNA has been detected in tears and conjunctival samples from infected individuals. Conjunctivitis is also reported in a small number of cases. We evaluated ocular symptoms and ocular tropism of SARS-CoV-2 in a group of patients with COVID-19.

METHOD

Fifty-six patients infected with SARS-CoV-2 were recruited as subjects. Relevant medical histories were obtained from the electronic medical record system. Ocular history and ocular symptoms data were obtained by communicating directly with the subjects. The Ocular Surface Disease Index (OSDI) and Salisbury Eye Evaluation Questionnaire (SEEQ) were used to assess the anterior ocular surface condition before and after the onset of disease.

RESULTS

Patients classified as severe COVID-19 cases were more likely to have hypertension compared to mild cases (p = 0.035). Of the 56 subjects, thirteen patients (23%) were infected in Wuhan, 32 patients (57%) were community-infected, 10 patients (18%) were unknown origin, 1 (2%) was a physician likely infected by a confirmed patient. Three patients wore face mask with precaution when contacting the confirmed patients. Fifteen (27%) had aggravated ocular symptoms, of which 6 (11%) had prodromal ocular symptoms before disease onset. The differences in mean scores of OSDI questionnaire and SEEQ between before and after onset of COVID-19 were all significant (p < 0.05 for both).

CONCLUSIONS

Ocular symptoms are relatively common in COVID-19 disease and may appear just before the onset of respiratory symptoms. Our data provided the anecdotal evidences of transmission of SARS-CoV-2 via ocular surface.

An investigation of low power convex lenses (adds) for eyestrain in the digital age (CLEDA)

INTRODUCTION

Digital eye strain (DES; computer vision syndrome) is a common cause of symptoms when viewing digital devices. Low-powered convex lenses (adds) have been recommended for the condition and "accommodative support" designs developed on this premise. The present research reports the extent to which dry eye is present in this population and the effect of convex lenses on symptoms and visual performance.

METHODS

The CVS-Q instrument was used to select pre-presbyopic adults with the symptoms of DES. Participants received a full eye examination including an assessment of dry eye with a modified SANDE questionnaire and using DEWS I criteria. The immediate effect of low-powered convex lenses (low adds: +0.50D, +0.75D, +1.25D) was investigated using subjective preference and a double-masked comparison with plano lenses with the Wilkins Rate of Reading Test (WRRT). Throughout this testing, participants wore their full distance refractive correction, based on non-cycloplegic retinoscopy and subjective refraction.

RESULTS

The signs and symptoms of dry eye were frequently present. Most participants reported a subjective preference for low adds, with +0.75D the most commonly preferred lens. Low adds (+0.50D and +0.75D; but not +1.25D) were associated with significantly improved performance at the WRRT. One quarter of participants read more than 10% faster with these additional convex lenses.

CONCLUSIONS

The study population was aged 20-40y and mostly worked on desktop computers. It is possible that +1.25D add may be more advantageous for people who are older or work more at closer viewing distances. Many symptomatic users of digital devices report a preference for low adds and use of these lenses is often associated with an improvement in reading performance.

Refinement of the Child Amblyopia Treatment Questionnaire (CAT-QoL) using Rasch analysis

Aims or Purpose: The Child Amblyopia Treatment Questionnaire (CAT-QoL) was developed using a "bottom-up" methodological approach. Interviews with children with amblyopia identified items (questions) and response levels to be tested in a draft questionnaire consisting of 11 items (sad, feeling on face, hurt, doing schoolwork, cross, how other children treat you, doing things, worried, upset with family, playing with friends, happy). This study describes the refinement of the descriptive system for the CAT-QoL instrument using the application of Rasch analysis. Methods: A multi-centre pilot study was conducted, and data collected from 342 participants. Participants were asked to self-complete the appropriate treatment version of the CAT-QoL questionnaire socio-demographic and clinical data were collected by the clinician using a standardised proforma. A "measure" of child's health was obtained from the parent by asking how they would rate their child's health over the previous week. Rasch analysis techniques were applied to refine the questionnaire. Rasch was used to examine response categories and collapse item response levels, identify poorly performing items, and explore local dependency of items. Results: A total of 331 subjects were included in the study sample, however only 315 were accepted into the RUMM program as a number of subjects had missing questions responses on the CAT-QoL. RUMM also excluded a further 41 subjects as these demonstrated extreme responses. Disordered response categories were found for each item, requiring adjacent response levels to be combined. This was applied to all items, and the model fit was re-examined. Two items were found to have poor fit (cross and happy) and were removed from the measure and the model fit was re-examined. No statistically significant differential item functioning (DIF) was found for any item, using person factors of age, sex or general health. Two items showed some dependency (worried and upset with family), and the poorer fitting item was subsequently removed (upset with family). This resulted in a refined CAT-QoL instrument that consists of 8-items, each with three-level response scales. Conclusion: The refined CAT-QoL instrument includes the following items: sad, feeling on face, hurt, doing work at school, how other children treat you, doing things, worried and playing with friends. The CAT-QoL can be Rasch scored, with a range of 0-16 where a greater value indicates a worse quality of life (or greater impact of treatment on the individual). The CAT-QoL may be useful in determining how amblyopia treatment affects children, and offers an alternative to generic patient reported outcome measures.

Psychometric Analysis of the SPEED Questionnaire and CLDEQ-8

Purpose

This study reports on the ability of the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire to detect dry eye (DE) symptoms in contact lens (CL) and non-CL wearers.

Methods

The SPEED questionnaire was administered to all subjects while the Contact Lens Dry Eye Questionnaire-8 (CLDEQ-8) was only administered to CL wearers. Tear meniscus heights (TMH) were measured, and the phenol red thread (PRT) test was conducted. These tests along with self-reported DE were used to identify subjects with dry eye disease (DED). Rasch analysis was performed to evaluate the questionnaires for measurement precision and unidimensionality, and the scores from these Rasch analyses were used to understand their ability to predict measures of DED.

Results

We enrolled 284 subjects (150 CL and 134 non-CL wearers). Mean subject age was 39.4 ± 14.2 years. Rasch analysis yielded a multidimensional short form of the SPEED questionnaire (8-items) and a unidimensional short form of the CLDEQ-8 (4-item). Scores from both questionnaires were significantly associated with self-reported DE in CL and non-CL wearers. Scores of the 8-item SPEED questionnaire were associated with DED status in non-CL wearers but not in CL wearers while 4-item CLDEQ scores were associated with DED status in CL wearers. TMH or PRT were not associated with either questionnaire in CL or non-CL wearers.

Conclusions

The 8-item SPEED questionnaire demonstrated adequate measurement precision with evidence of quantifying multiple symptoms categories while the 4-item CLDEQ-8 primarily quantified DE symptoms. Questionnaire scores were associated with self-reported DE, which suggests that they may have utility in both populations analyzed.

Five levels of performance and two subscales identified in the computer-vision symptom scale (CVSS17) by Rasch, factor, and discriminant analysis

PURPOSE

To quantify the levels of performance (symptom severity) of the computer-vision symptom scale (CVSS17), confirm its bifactorial structure as detected in an exploratory factor analysis, and validate its factors as subscales.

METHODS

By partial credit model (PCM), we estimated CVSS17 measures and the standard error for every possible raw score, and used these data to determine the number of different performance levels in the CVSS17. In addition, through discriminant analysis, we checked that the scale's two main factors could classify subjects according to these determined levels of performance. Finally, a separate Rasch analysis was performed for each CVSS17 factor to assess their measurement properties when used as isolated scales.

RESULTS

We identified 5.8 different levels of performance. Discriminant functions obtained from sample data indicated that the scale's main factors correctly classified 98.4% of the cases. The main factors: Internal symptom factor (ISF) and external symptom factor (ESF) showed good measurement properties and can be considered as subscales.

CONCLUSION

CVSS17 scores defined five different levels of performance. In addition, two main factors (ESF and ISF) were identified and these confirmed by discriminant analysis. These subscales served to assess either the visual or the ocular symptoms attributable to computer use.

Evaluation of Reliability and Validity of Three Common Dry Eye Questionnaires in Chinese

Purpose

To investigate the psychometric properties of three commonly used dry eye questionnaires including McMonnies Questionnaire (MQ), the Ocular Surface Disease Index (OSDI), and the Salisbury Eye Evaluation Questionnaire (SEEQ) in Chinese.

Methods

This prospective cross-sectional study was conducted at the Eye Hospital of Wenzhou Medical University. Ninety-eight participants completed three questionnaires in a random order. Ophthalmic examinations including tear break-up time, corneal fluorescein staining score, and Schirmer I test were performed. Reliability, validity, and accuracy were assessed for three questionnaires.

Results

There were 35 mild-to-moderate dry eye patients, 14 severe dry eye patients, and 49 non-dry eye patients. The Cronbach α of MQ, OSDI, and SEEQ was 0.54, 0.74, and 0.76, respectively, and the intraclass correlation coefficients were 0.91, 0.90, and 0.94, respectively. There were significant differences (P < 0.05) in MQ and OSDI scores among different groups, but there were no statistically significant differences between the mild-to-moderate group and the severe group in terms of SEEQ scores. With cutoff values for abnormal MQ of 15, OSDI of 27.2, and SEED of 1, respectively, good dry eye diagnostic accuracies were obtained.

Conclusions

The three questionnaires showed fair accuracy in the diagnosis of dry eye. The cutoff values of OSDI changed when applied to Chinese people.