The VF-14 index of visual function in recipients of a corneal graft: a 2-year follow-up study

Economic appraisal of prosthetic replacement of ocular surface ecosystem in Canada

OBJECTIVE

To perform an economic appraisal of the Prosthetic Replacement of Ocular Surface Ecosystem (PROSE; BostonSight, Needham Heights, Mass.) lens in patients with a distorted corneal surface or ocular surface disease in Canada.

DESIGN

Retrospective observational cohort study with cost, cost-utility, and benefit-cost analyses.

PARTICIPANTS

Patients who received PROSE from the only PROSE clinic in Canada from 2018 to 2020.

METHODS

Visual acuity (VA) outcomes of the participants were assessed. Benefits were defined as VA improvements that were converted into utilities and then quality-adjusted life years. Economic values were derived via government statements, clinic financial statements, and published literature.

RESULTS

Average best-corrected VA (BCVA) improvement was -0.42 ± 0.41 logMAR (p = 2.68 × 10^-13) or Snellen 20/53 for the overall cohort, -0.51 ± 0.48 (p = 5.42 × 10^-8) or Snellen 20/65 for distorted corneal surface patients, and -0.31 ± 0.30 (p = 1.30 × 10^-7) or Snellen 20/41 for ocular surface disease patients. This corresponded to discounted quality-adjusted life year gains of 0.51, 0.65, and 0.42, respectively, over an estimated 5-year PROSE device lifespan. Average cost to fit a patient with PROSE was USD$5 469.85 (CAD$7 087.28), of which USD$4 971.38 (CAD$6 441.42) was clinic cost and USD$498.47 (CAD$645.87) was patient cost. Cost-utility was USD$10 256.47 (CAD$13 289.31) for the overall cohort, USD$8 439.79 (CAD$10 935.44) for distorted corneal surface patients, and US$13 069.90 (CAD$16 934.67) for ocular surface disease patients. The benefit-cost ratio was 34.4 for all, 43.8 for distorted corneal surface patients, and 28.3 for ocular surface disease patients.

CONCLUSIONS

Our economic appraisal demonstrated that PROSE treatment provides a significant, cost-effective benefit to Canadian patients with distorted corneal surfaces and ocular surface diseases. This indicates that PROSE clinics are an efficient investment.

Microthin Descemet Stripping Automated Endothelial Keratoplasty Versus Descemet Membrane Endothelial Keratoplasty: A Randomized Clinical Trial

PURPOSE

To compare visual outcomes, complications, and vision-related quality of life (QoL) after microthin Descemet stripping automated endothelial keratoplasty (MT-DSAEK) versus Descemet membrane endothelial keratoplasty (DMEK) for the management of corneal endothelial dysfunction in Fuchs dystrophy.

METHODS

This is a prospective, double-blinded randomized controlled clinical trial. Patients with visually significant endothelial decompensation from Fuchs dystrophy were prospectively randomized to receive MT-DSAEK or DMEK surgery. The primary outcome was best spectacle-corrected visual acuity (BSCVA) at 12 months. Secondary outcomes included refraction, keratometry, endothelial cell count, complications, and vision-related QoL at 6 and 12 months postoperatively.

RESULTS

A total of 56 eyes of 56 patients were enrolled, 28 in each group. Postoperatively, LogMAR mean BSCVA in the MT-DSAEK group was 0.17 ± 0.08 and 0.11 ± 0.09 at 6 and 12 months compared with 0.09 ± 0.13 and 0.04 ± 0.13 after DMEK (P = 0.03, P = 0.002 respectively) with the DMEK cohort achieving 3.5 logarithm of the minimum angle of resolution letters better BSCVA at 1 year compared with MT-DSAEK. Complication rates were similar with 3.5% rebubbling rate in both groups, 1 primary graft failure in DMEK and a single endothelial rejection in the MT-DSAEK arm. Vision-related QoL was comparable at 6 and 12 months postoperatively, and no eyes demonstrated loss of vision from preoperative BSCVA.

CONCLUSIONS

DMEK surgery resulted in significantly better BSCVA at 1, 3, 6, and 12 months postoperatively compared with MT-DSAEK. Patient satisfaction was similar with no differences reported in vision-related QoL scores, as was the complications profile between groups. Thus, our results favor DMEK as the better choice procedure for eyes with Fuchs-related corneal decompensation without ocular comorbidities.

Vision related quality of life of patients with keratoconus after keratoplasty at a Tertiary Eye Hospital in Saudi Arabia

PURPOSE

To assess the vision-related quality of life (VQoL) for patients with advanced keratoconus (KC) after primary keratoplasty.

METHODS

This was a cross-sectional study, undertaken at the King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia, in December 2015. Adults (aged 22-75 years) were interviewed via telephone with regard to their VQoL, on the average, 5 years after undergoing primary keratoplasty for advanced KC. VQoL was measured using the Visual Functioning Index (VF-14, Arabic version). The relationship between VQoL and different demographic and clinical factors was evaluated using linear regression.

RESULTS

Ninety-five adults participated in the study (54.7 % males; mean age at the interview = 32.05 ± 7.18 years). Eighty-seven (91.6%) of them had undergone PKP. The overall mean VF-14 score was 86.19% (SD: 12.91). VF-14 score was significantly lower for individuals with higher log average K (beta coefficient, -28.32; 95% confidence interval [CI], -55.59 to -1.04; p = 0.042) and hazy graft (beta coefficient, -12.76; 95% CI, -21.16 to -4.36; p = 0.003) adjusting for the effect of keratoplasty technique and BCVA in the better eye at the last follow up.

CONCLUSION

This study suggests that most patients with advanced keratoconus had satisfactory VQoL after primary keratoplasty. Certain subgroups may benefit less substantially than others and would need a particular attention.

Effect of Corneal Transplantation on Patient-Reported Outcomes and Potential Predictors: A Systematic Review

PURPOSE

To investigate the effect and potential predictors of corneal transplantation on patient-reported outcomes such as quality of life, visual functioning, and mental health by systematically reviewing the literature.

METHODS

Studies with 1 preoperative and at least 1 postoperative measurement were searched for in relevant literature databases. Methodological quality was assessed using the Quality Assessment Tool for Quantitative Studies, and effect sizes were calculated.

RESULTS

Of 1445 unique publications, 14 studies, including 15 study designs, were described in 16 publications. Four randomized controlled trials, 1 controlled clinical trial, 1 cohort study, and 1 before-after study (BA) were of good quality; 6 BAs were of moderate quality; and 2 BAs were of weak quality. Patients generally improved 12 months after transplantation on health-related quality of life (effect size between 0.08 and -3.06), vision-related quality of life (-0.67 and -6.65), visual functioning (-0.55 and -0.63), and subjective visual symptoms (-0.31 and -0.86). Patient satisfaction was high (-0.95). Patients improved on depression (-0.31) but remained stable on anxiety (-0.05) 4 months after transplantation. Predictors of positive outcomes were lower preoperative visual acuity and visual functioning, better postoperative visual factors, younger age, and male sex.

CONCLUSIONS

Corneal transplantation showed overall beneficial effects on patient-reported outcomes. Knowledge of these effects and predictors might result in better treatment, more patient-centered care, and more realistic expectations on the part of patients and ophthalmologists. Future studies should focus on not only health- and vision-related quality of life but also mental health and labor participation using longitudinal study designs.

Evaluation of the quality of life related to vision after penetrating keratoplasty

INTRODUCTION

Organ and tissue donation and transplantation represent the most important therapeutic advance of current times. The cornea is, by far, one of the most transplanted tissues worldwide due to the immune privilege of this tissue, as well as the advances in microsurgery, existence of cornea banks, preservation of corneas, and use of anti-rejection therapy. However, many patients with successful corneal transplants (with clear corneas) experience poor vision in the post-operative period due to irregular astigmatism, or other complications.

OBJECTIVE

To evaluate the quality of life related to vision in patients undergoing penetrating keratoplasty.

MATERIAL AND METHODS

A cross-analytical study including patients with a history of penetrating keratoplasty, over 18years of age, and at least 6months after surgery. The patients answered the Visual Function Questionnaire25 (VFQ-25) of visual function, a tool validated for use in Spanish, in which the higher the score, the better the quality of life.

RESULTS

Thirty patients (20men and 10women), with a mean age of 61.2±18.7years, were included. The time of evolution after the transplant was 17.7±4months. The total quality of life score was 74.9±21.9, with significance in visual acuity (P<.001), and the presence of systemic comorbidities (P=.018). There was no significance between the transplant reason (P=.098) or ocular comorbidities (P=.119).

CONCLUSION

The results suggest that visual acuity, as well as the presence of systemic comorbidities, has a significant impact on quality of life.

Evaluation of quality of life after implantation of a new trifocal intraocular lens

PURPOSE

To evaluate the vision-related quality of life (QOL) after implantation of a new trifocal intraocular lens (IOL), by using the National Eye Institute Visual Function Questionnaire-14 (VF-14 QOL questionnaire).

SETTING

Baskent University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey.

DESIGN

Prospective noncomparative case series.

METHODS

Consecutive patients who had a new trifocal IOL (PanOptix) bilaterally implanted were included in the study. The vision-related QOL was assessed 3 months after the surgery in the second eye. The VF-14 QOL questionnaire was used, with a grading scale of 0, no difficulty; 1, a little difficulty; 2, moderate difficulty; 3, quite difficult; 4, impossible to perform. A subgroup of 14 patients, with an interval of at least 3 months between the surgery in the first eye and the surgery in the fellow eye, were also interviewed 3 months after the monocular IOL implantation. In this subgroup, the QOL with monocular and binocular implantation was compared.

RESULTS

The study comprised 48 patients. Reading small print, driving at night, and doing fine handwork were the most difficult tasks to perform, with the mean values of the VF-14 QOL questionnaire being 0.94 ± 0.81 (SD), 0.89 ± 0.68, and 0.64 ± 0.67, respectively. Binocular implantation was associated with improvement in vision-related QOL when compared with monocular implantation, with significant differences in doing fine handwork such as sewing (P = .02) and using a computer (P = .03).

CONCLUSIONS

With mean values of 1.00 or lower for each question, the results of the VF-14 QOL questionnaire indicated that patients who have the new trifocal IOL bilaterally implanted have an overall high satisfaction rate and a high vision-related QOL.

Correlational Analysis of Objective and Subjective Measures of Cataract Quantification

PURPOSE

To evaluate whether correlations exist between objective and subjective measures of vision quality as a consequence of cataract and whether this may qualify the Objective Scatter Index as a supplementary means of cataract assessment.

METHODS

A prospective multicenter, cross-sectional study was conducted in 10 centers across France in patients undergoing cataract extraction surgery (lens opacity evaluated with the Lens Opacities Classification System III). A quality of life assessment using the Visual Function Index-14 (VF-14) (14 questions scored from 0 to 4) and measurement of visual acuity and evaluation of the Objective Scatter Index (HD Analyzer, Visiometrics SL, Terrassa, Spain) to assess the alteration of light scatter were used as measures in the study.

RESULTS

The study included 1,768 eyes of 1,768 patients (mean age: 72.5 years; range: 28 to 93 years). The average OSI score was 4.97 ± 3.13 (range: 0.4 to 20.5). There was good correlation between visual acuity and OSI (r = -0.47, P < .001) and between OSI and VF-14 (r = -0.11, P < .001).

CONCLUSIONS

The results presented in this study confirm that the Objective Scatter Index has sufficient correlations with visual acuity and VF-14 to supplement existing cataract diagnosis in a large population encompassing a broad spectrum of cataract presentations.

Development and validation of an Arabic version of the Visual Functioning Index VF-14 for cataract patients

Purpose:

To develop and validate an Arabic version of the Visual Functioning Index (VF-14) for patients with cataracts.

Materials and Methods:

The VF-14 was translated into Arabic by an epidemiologist and an ophthalmologist, both fluent in Arabic and English. The VF-14 was administered to patients diagnosed with cataract at two hospitals in Egypt and two hospitals in Saudi Arabia. Patients were also administered three other forms; the cataract symptoms score (CSS); global measure of vision; and cataract medical form. Internal reliability and external validity were measured. Index sensitivity to visual acuity was detected and potential effective factors were investigated. Correlation analyses were performed. A p value less than 0.05 was considered statistically significant.

Results:

The translated VF-14 was consistent and reliable (σ = 0.763, p < 0.0001). It was also statistically significantly sensitive to vision (p < 0.0001). The mean calculated index was 62.18 ± 19.34, and was highly correlated with; CSS and other scores (p < 0.0001, all cases). Factors that may affect the index are; age, sex, vision, wearing glasses, type, position, and severity of cataract.

Conclusion:

The Arabic VF 14 is a reliable and valid tool for evaluation of both visual functioning and quality of visual life among cataract patients. It is also sensitive to changes in visual acuity, demographic, and clinical characteristics.

Health status and patient satisfaction after corneal graft: results from the corneal transplant epidemiological study

Purpose. To evaluate effects of corneal transplantation on the health-related quality of life and patients' satisfaction. Methods. Patients scheduled for elective penetrating or anterior lamellar keratoplasty completed by telephone interview the SF-12 Health Survey, before and one year after surgery, and a 6-item questionnaire on the satisfaction for graft outcomes. Results. The two questionnaires were answered by 1,223 patients. Transplantation did not influence the PCS-12 in males (ES = -0.01) and had a negative effect in females (ES = -0.18). Both sexes improved their MCS-12 (ES = 0.18 and 0.23, resp.). The majority of patients (83.1%) were satisfied by the outcome of the graft. Conclusions. This is the first report on the use of the SF-12 and one of the few that assess quality of life in patients after corneal transplantation. We showed that grafting improves patients' health-related quality of life results of patients, influencing mental health (i.e., psychological attitude, social interaction, and emotions) with minor effects on physical health (limitation, pain, and vitality).

Incremental cost-utility analysis of deep anterior lamellar keratoplasty compared with penetrating keratoplasty for the treatment of keratoconus

PURPOSE

This study sought to determine the cost effectiveness of deep anterior lamellar keratoplasty (DALK) compared with penetrating keratoplasty (PK) for the treatment of keratoconus. DALK is associated with lower rates of postoperative complications compared with PK, but is a more expensive procedure; whether it is cost effective compared with PK is unknown.

DESIGN

The study was an incremental cost-utility analysis from a health systems perspective using retrospective data on a cohort of patients with severe keratoconus.

METHODS

The analysis was conducted using 1-year cost and outcomes data from 148 keratoconus patients, representing 102 PK and 46 DALK cases, seen for corneal grafts between January 1991 and January 2009 at the Singapore National Eye Center. The main outcome assessed was the incremental cost-utility ratios associated with PK and DALK for the treatment of keratoconus.

RESULTS

Over a 20-year period, PK was the lower cost procedure and had an incremental cost-utility ratio of $3,750 per quality-adjusted life-year compared with no surgical treatment. Compared with PK, DALK has an incremental quality-adjusted life-year gain of 0.8 and an incremental cost of $2,420, for an incremental cost-utility ratio of $3,025 per quality-adjusted life-year.

CONCLUSIONS

Compared with PK, DALK has a favorable cost-effectiveness ratio and, resources permitting, should be considered as a first-line treatment for keratoconus. Additional studies are needed to confirm the expected advantages of DALK over PK when it comes to long-term graft failure rates.

Keratoconus in Asians: demographics, clinical characteristics and visual function in a hospital-based population

BACKGROUND

To describe the demographics, clinical characteristics and visual function of Asian patients with keratoconus managed in a tertiary eye centre.

DESIGN

Prospective cross-sectional study.

PARTICIPANTS

116 patients with clinically evident or suspected keratoconus (on videokeratography) recruited over 11 months.

METHODS

A standardised interview, full ophthalmic examination, refraction and corneal topography were performed. Visual function was assessed with the VF-14 questionnaire.

MAIN OUTCOME MEASURES

Demographics, clinical characteristics and visual function.

RESULTS

Mean age of our patients was 29.5 ± 9.40 years on enrolment, 62.9% were male, and the ethnic distribution was 60.3% Chinese, 13.8% Malays and 9.5% Indians. Clinically evident keratoconus was present bilaterally in 65 patients (56.0%) and unilateral keratoconus in five patients (4.3%). Five patients (4.3%) had a family history of keratoconus. The majority of patients were managed with contact lenses (60.8%) or glasses (24.5%). Eye rubbing was common (68%) as were asthma (26.3%) and eczema (18.4%). Conical protrusion was the commonest sign (75.3%). The mean cylinder was higher in keratoconus eyes compared with keratoconus suspect eyes (-4.01 vs. -1.27, P < 0.001), and best-corrected visual acuity was poorer (0.19 vs. 0.05, P < 0.001). Unaided visual acuity was significantly worse with increasing age (P = 0.016). On the VF-14, 32% scored 90 or less (out of 100), reflecting difficulties with vision-related daily activities.

CONCLUSIONS

Our Asian patients with keratoconus had similar demographic and clinical characteristics to patients in Western populations. Even with apparently good visual acuity, some patients still experience substantial impairment in vision-related activities.

The impact of penetrating keratoplasty in patients with keratoconus using the VF-14 questionnaire

To assess the visual function of patients with keratoconus who underwent penetrating keratoplasty with the use of the VF-14 questionnaire. Fourteen patients (9 male and 5 female) with a mean age of 38 years (SD 13.59) participated in the study. All patients had keratoconus, confirmed by corneal topography, and all had previously undergone penetrating keratoplasty in one eye. Their mean best-corrected visual acuity (BCVA) binocularly was 0.185 (SD 0.077) LogMAR. None of the grafted eyes had a BCVA < 0.300 LogMAR. Fourteen healthy volunteers, age- and sex-matched, also participated in the study as control subjects. The VF-14 questionnaire was used to evaluate the effect of the ocular status in the daily life activities of the patients. The mean VF-14 result for the grafted patients with keratoconus was 62.37% (SD 22.60) and for the control group it was 100% (P < 0.001). There was only a weak correlation between the VF-14 score and the binocular BCVA (r = -0.394, P = 0.163). The mean VF-14 result in grafted patients with keratoconus is indicative of low functional ability despite the satisfactory postoperative BCVA. The absence of a significant correlation between the VF-14 score and the mean BCVA indicates that the low functional visual ability in these patients is probably associated more with the 'perceived by themselves' difficulty due to their ophthalmological condition.

Psychological distress and visual functioning in relation to vision-related disability in older individuals with cataracts

OBJECTIVE

To determine whether demographic, health status and psychological functioning measures, in addition to impaired visual acuity, are related to vision-related disability.

METHODS

Participants were 105 individuals (mean age=73.7 years) with cataracts requiring surgery and corrected visual acuity in the better eye of 6/24 to 6/36 were recruited from waiting lists at three public out-patient ophthalmology clinics. Visual disability was measured with the Visual Functioning-14 survey. Visual acuity was assessed using better and worse eye logMAR scores and the Melbourne Edge Test (MET) for edge contrast sensitivity. Data relating to demographic information, depression, anxiety and stress, health care and medication use and numbers of co-morbid conditions were obtained.

RESULTS

Principal component analysis revealed four meaningful factors that accounted for 75% of the variance in visual disability: recreational activities, reading and fine work, activities of daily living and driving behaviour. Multiple regression analyses determined that visual acuity variables were the only significant predictors of overall vision-related functioning and difficulties with reading and fine work. For the remaining visual disability domains, non-visual factors were also significant predictors. Difficulties with recreational activities were predicted by stress, as well as worse eye visual acuity, and difficulties with activities of daily living were associated with self-reported health status, age and depression as well as MET contrast scores. Driving behaviour was associated with sex (with fewer women driving), depression, anxiety and stress scores, and MET contrast scores.

CONCLUSION

Vision-related disability is common in older individuals with cataracts. In addition to visual acuity, demographic, psychological and health status factors influence the severity of vision-related disability, affecting recreational activities, activities of daily living and driving.

Clinical benefits of the Boston Ocular Surface Prosthesis

PURPOSE

To evaluate the effects of the Boston Ocular Surface Prosthesis (Boston Foundation for Sight, Needham, Massachusetts, USA) on visual acuity (VA) and visual functioning in patients with severe corneal ectasia, irregular astigmatism, or ocular surface disease.

DESIGN

Prospective, interventional case series.

METHODS

The study examined the effects of this prosthesis on VA and visual functioning in consecutive patients with corneal ectasia, irregular astigmatism, or ocular surface disease who had failed conventional therapies and were seen at the Boston Foundation for Sight between January 1 and June 30, 2006. Outcomes were best-corrected VA using Snellen charts and visual functioning using the National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25) at 6 months. Clinical data were abstracted from medical records.

RESULTS

Of the 101 patients, 80 were fitted with a prosthesis in one or both eyes, and follow-up Visual Functioning Questionnaire data were obtained in 69 eyes. Best-corrected VA improved by a change in mean logarithm of the minimal angle of resolution (logMAR) units of -0.39 (converted from Snellen) with a change of -0.54 logMAR units in patients with ectasia or astigmatism and -0.22 logMAR units in patients with ocular surface disease. Mean composite visual functioning scores increased from 57.0 to 77.8 (P < .0001). Improvements in composite Visual Functioning Questionnaire scores were similar in patients with ectasia or ocular surface disease; but vision-related subscores improved more in patients with ectasia, whereas subscores for ocular pain, role difficulties, and dependency improved more in patients with ocular surface disease.

CONCLUSIONS

The Boston Ocular Surface Prosthesis significantly improved VA and visual functioning in patients with corneal ectasia, irregular astigmatism, and ocular surface disease who had failed conventional therapies.

Economic appraisal of the Boston Ocular Surface Prosthesis

PURPOSE

To perform an economic appraisal of the Boston Ocular Surface Prosthesis in patients with corneal ectasia, irregular astigmatism, or ocular surface disease.

DESIGN

Cost, incremental cost-effectiveness, and benefit-cost analyses in a prospective observational study.

METHODS

The effects of this scleral lens on visual functioning were measured in 69 patients who received the prosthesis in 2006 and were reassessed 6 months after fitting the prosthesis. Benefits, based on improvements in visual functioning, were converted to quality-adjusted life years (QALYs), and economic values were derived using results from published studies. Costs were estimated from the provider organization's 2006 operating financial statement with additions for donated resources and future scale-up.

RESULTS

Mean scores on a 100-point visual functioning questionnaire (VFQ-25) improved from 57.0 to 77.8 (P < .0001). On average, each fitted patient cost $11,841 ($6001 for clinical services and $5840 to produce the prosthesis). Patients' quality of life improved by 0.10 QALYs per year. Assuming that benefits persist for an average of 5 years, the lifetime gain was 0.48 QALYs; the average cost-effectiveness of the prosthesis was $24,900 per QALY (95% confidence interval $19,100 to $29,600), and the average benefit-cost ratio was 4.0 to 1. In patients with the lowest baseline scores (average VFQ score 38.6), results were even more favorable: cost-effectiveness $17,100 per QALY and benefit-cost ratio 5.6 to 1.

CONCLUSIONS

The Boston Ocular Surface Prosthesis is cost-effective and cost beneficial in patients with severely compromised visual function attributable to ectasia, irregular astigmatism, or ocular surface disease.

The quality of life impact of peripheral versus central vision loss with a focus on glaucoma versus age-related macular degeneration

PURPOSE

It is well accepted that conditions that cause central vision loss (CVL) have a negative impact on functional ability and quality of life (QoL), but the impact of diseases that cause peripheral vision loss (PVL) is less well understood. Focusing on glaucoma and age-related macular degeneration (ARMD), the effects of CVL and PVL on QoL were compared.

METHODS

A systematic literature review of publications reporting QoL in patients with CVL or PVL identified 87 publications using four generic (Short-Form Health Survey-36 and -12, EuroQoL EQ-5D and Sickness Impact Profile) and five vision-specific (National Eye Institute Visual Function Questionnaire-51, -39, and -25, Impact of Vision Impairment and Visual Function-14) QoL instruments; 33 and 15 publications reported QoL in ARMD and glaucoma, respectively.

RESULTS

QoL was impaired to a similar extent by diseases associated with PVL and CVL, but different domains were affected. In contrast to ARMD, mental aspects appeared to be affected more than physical aspects in patients with glaucoma.

CONCLUSIONS

The differential impact upon QoL might be a function of the pathology of the diseases, for example potential for blindness and better ability to perform physical tasks due to retention of central vision may explain these observations in glaucoma.

The Eye Sensation Scale: an ophthalmic pain severity measure

PURPOSE

The aim was to develop a single-item, categorical ophthalmic pain severity scale.

METHODS

Focus groups were held with people who had experienced ophthalmic pain. Participants described their ophthalmic pain experiences with reference to level of severity, and commented on proposed pain scale designs. Thematic analysis of transcripts, and participants' category choices and scale preferences, were used to determine the number of response categories and labels chosen for the instrument. The final instrument was evaluated using a mail-out questionnaire.

RESULTS

Five ophthalmic pain domains were identified: intensity; nature (including subdomains: physical sensation, temporal patterning, simile/metaphor); physical effects; emotional effects; and behavioral effects. The most frequent descriptors were physical sensation (n = 160), behavioral effects (n = 87), and physical effects (n = 68). Participants preferred a five-category scale. The higher frequency severity descriptors used by the participants formed the basis for the category labels for the instrument ("extreme," "severe," "moderate," "mild," "none"). Notably, many participants rejected the word "pain" in favor of "discomfort" or "light sensitivity." Participants commonly linked severity and nature descriptors; however, the same nature descriptor (e.g., "ache" or "scratching") did not confer the same pain severity between participants.

CONCLUSIONS

A five-category scale was chosen for assessing the severity of ophthalmic sensations: the Eye Sensation Scale. The scale involves rating the severity of the ophthalmic sensation that is most important to the patient and provides the opportunity to describe other attributes or effects of the sensation. Evaluation indicated the adequacy of the final instrument.

The impact of cataract surgery on visual functioning, vision-related disability and psychological distress: a randomized controlled trial

PURPOSE

Determine whether there are changes in visual functioning, vision-related disability, health status and mood after cataract surgery.

METHODS

45 adults (mean age = 73.7 years) with bilateral cataract needing surgery for the first eye were recruited from public ophthalmology clinics. The Visual Functioning-14 survey assessed visual disability. Minimal angle of resolution tested visual acuity, and the Melbourne Edge Test examined contrast sensitivity. Demographic, psychological, health and medication use variables were examined. Participants were randomized to either an intervention or control arm. Controls were assessed on two occasions at a 3-month interval before having surgery. The intervention group was assessed 1-2 weeks before surgery and then reassessed 3 months after surgery.

RESULTS

Visual functioning improved for those who had cataract surgery with better visual acuity in the better (P = 0.010) and worse (P = 0.028) eye compared with controls. The intervention group reported fewer difficulties with overall vision-related disability (P = 0.0001), reading (P = 0.004) and instrumental activities of daily living (P = 0.010) post-surgery compared with controls. People with improved depression scores (P = 0.048) after surgery had less difficulty with reading compared with those with unchanged or worsened depression scores. Cataract surgery did not improve health status.

CONCLUSIONS

First eye cataract surgery is effective in improving outcomes in visual functioning and disability. Improved mood after surgery was related to less vision-related disability compared with unchanged or worse depression.

Responsiveness of the National Eye Institute Visual Function Questionnaire to progression to advanced age-related macular degeneration, vision loss, and lens opacity: AREDS Report no. 14

OBJECTIVE

To describe the ability of the National Eye Institute Visual Function Questionnaire (NEI-VFQ) to detect meaningful change over time (responsiveness) to the primary Age-Related Eye Disease Study outcomes.

METHODS

The 25-item NEI-VFQ plus appendix was administered at 2 visits at 1- to 4-year intervals to 4119 participants in the Age-Related Eye Disease Study. Events evaluated were progression to advanced age-related macular degeneration (AMD), visual acuity (VA) loss of at least 15 letters, and lens opacity progression. Responsiveness was measured by the t statistic, effect size (ES), responsiveness statistic, and area under the receiver operating characteristic curve. Variance components were used to estimate the contributions of events to variability of the NEI-VFQ score.

RESULTS

Overall NEI-VFQ score was responsive to AMD progression (t = 14.0; P< .001; ES = 0.81) and VA (t = 16.2; P< .001; ES = 0.74). Mean changes ranged from 11 to 25 points for the subscales of general vision, near and distance activities, social functioning, mental health, role difficulties, dependency, and driving. The NEI-VFQ was unresponsive to lens opacity progression, although when the event occurred in the eye with the best vision at the first administration, the lens opacity ES was moderate for the color vision (ES = 0.62) and driving subscales (ES = 0.66). Progression to advanced AMD and VA loss contributed significantly to the variation in the mean difference in overall VFQ score.

CONCLUSIONS

Changes in the NEI-VFQ overall and subscale scores of 10 points or more are associated with clinically significant changes in vision and AMD. This finding may assist the design of interventional studies of AMD and VA loss that include the NEI-VFQ as an outcome measure.

Clinical research, comparison of the subjective visual function in patients with epiphora and patients with second-eye cataract

PURPOSE

To assess the subjective visual disability of patients with epiphora and to compare the results with that of patients waiting for second eye cataract surgery.

DESIGN

A prospective, randomised, questionnaire-based study.

METHODS

Forty-six patients with epiphora listed for dacryocystorhinostomy and 50 patients having second eye cataract extraction were enrolled. A questionnaire focusing on functional visual disability in daily life and based on VF-14 was completed for each participant.

RESULTS

Eighty-six percent of patients with epiphora and 41% of second-eye cataracts had difficulty reading small print (P < 0.05). The extent of such difficulty was moderate to great in 48% of epiphora and only 26% of cataract patients .A substantial percentage of epiphora patients and second eye cataract also reported difficulty with other tasks, such as doing fine work (78.9% vs. 42%) (P < 0.05), watching television (63.1% vs. 19%) (P < 0.05), seeing steps or stairs (43.4% vs. 10%) (P < 0.05), or reading signs (39.1% vs. 4%) (P < 0.05), respectively.

CONCLUSIONS

There is widespread recognition of the effect of cataract on visual function. This has resulted in substantial government funding to improve access to cataract surgery. In comparison, epiphora is rarely considered as a significant cause of visual disability. This study suggests that patients with epiphora suffer the same if not more of a visual handicap than patients awaiting second eye cataract surgery.

Assessment of visual function after corneal transplantation: the quality of life and psychometric assessment after corneal transplantation (Q-PACT) study

PURPOSE

Many patients with successful corneal grafts have poor vision postoperatively. This study evaluates changes in vision-related quality of life after penetrating keratoplasty (PK).

DESIGN

Multicenter prospective cohort study.

METHOD

Penetrating keratoplasty candidates from the university-affiliated ophthalmology clinics of four participating centers were enrolled and followed up prospectively. We used the PK-VFQ, a modified version of the Visual Function Index-14, combined with clinical examinations before and at 6 and 12 months after PK. We used multivariate linear regression models to examine predictors of change in PK-VFQ scores.

RESULTS

We studied 74 grafts in 71 eyes of 67 patients aged 23 to 91 (mean, 61) years who were followed up for at least 6 months. Indications for surgery included bullous keratopathy (27%), scarring (16%), keratoconus (16%), dystrophies (16%), and regrafts (15%). Median preoperative visual acuity was 20/200 in the graft candidate and 20/30 in the best eye. Median best-corrected postoperative visual acuity in the operated eyes was 20/60 at 6 months. PK-VFQ scores improved at 6 months in 79% by an average of 13.0 points (range, -16.7 to 67.5). Improvement in PK-VFQ scores was associated with younger age (P =.04), poorer preoperative visual acuity in the best eye (P =.001), and postoperative contact lens use (P =.04) but not with postoperative acuity in the grafted eye (P =.49). Postoperatively, 80% of patients were moderately to very satisfied with their vision, and 97% of patients stated they would have the surgery again.

CONCLUSIONS

Improvement in visual function is inversely associated with visual acuity in the better-seeing eye but does not correlate with the postoperative acuity in the grafted eye. Although most keratoplasties are done unilaterally in the setting of good visual acuity in the contralateral eye, for the majority of patients visual function improves after PK.