Esterman disability rating in severe glaucoma

Glaucoma in Adults-diagnosis, Management, and Prediagnosis to End-stage, Categorizing Glaucoma's Stages: A Review

Importance

Most frequent worldwide cause of permanent blindness is glaucoma. Early in the course of the disease, glaucoma affects many patients without any symptoms. In order to examine for indications of glaucoma and to ascertain whether systemic illnesses or drugs can raise a patient's risk of developing glaucoma, primary care practitioners should be aware of which patients to send to an eye care specialist. A review of the pathogenesis, risk factors, screening, disease monitoring, and treatment options for open-angle and narrow-angle glaucoma are included.

Observations

The optic nerve and retinal nerve fiber layer (rNFL) are damaged in glaucoma, a chronic, progressive optic neuropathy that can result in a permanent loss of peripheral or central vision. The only risk factor that is known to be controllable is intraocular pressure (IOP). A family history of glaucoma, older age, and non-white race are additional significant risk factors. Numerous systemic diseases and drugs, such as corticosteroids, anticholinergics, certain antidepressants, and topiramate, can put people at risk of developing glaucoma. Open-angle and angle-closure glaucoma are the two main types of disease. Measurement of IOP, perimetry, and optical coherence tomography are diagnostic procedures to evaluate glaucoma and track the course of the condition. In order to treat glaucoma, IOP must be decreased. This is possible with a variety of glaucoma medication classes, laser surgery, and incisional surgery.

Verdicts and relevance

By identifying systemic illnesses and drugs that raise a patient's chance of developing glaucoma and referring high-risk individuals for a thorough ophthalmologic examination, vision loss from glaucoma can be reduced. Clinicians should make sure that patients continue taking their glaucoma drugs as prescribed and should keep an eye out for any negative side effects from any medical or surgical procedures used to treat glaucoma.

How to cite this article

Joshi P, Dangwal A, Guleria I, et al. Glaucoma in Adults-diagnosis, Management, and Prediagnosis to End-stage, categorizing Glaucoma's Stages: A Review. J Curr Glaucoma Pract 2022;16(3):170-178.

Relationship between Vision-Related Quality of Life and Central 10° of the Binocular Integrated Visual Field in Advanced Glaucoma

To investigate the relationships between sensitivity loss in various subfields of the central 10° of the binocular integrated visual field (IVF) and vision-related quality of life (VRQoL) in 172 patients with advanced glaucoma. Using the Random Forest algorithm, which controls for inter-correlations among various subfields of the IVF, we analysed the relationships among the Rasch analysis-derived person ability index (RADPAI), age, best-corrected visual acuity (BCVA), mean total deviations (mTDs) of eight quadrant subfields in the IVF measured with the Humphrey Field Analyzer (HFA) 10-2 program (10-2 IVF), and mTDs of the upper/lower hemifields in the IVF measured with the HFA 24-2 program (24-2 IVF). Significant contributors to RADPAIs were as follows: the inner and outer lower-right quadrants of the 10-2 IVF contributed to the dining and total tasks; the lower-left quadrant of the 10-2 IVF contributed to the walking, going out and total tasks; the lower hemifield of the 24-2 IVF contributed to the walking, going out, dining, miscellaneous and total tasks; and BCVA contributed more to the letter, sentence, dressing and miscellaneous tasks than to others. The impact of damage in different 10-2 IVF subfields differed significantly across daily tasks in patients with advanced glaucoma.

Utility of CLOCK CHART binocular edition for self-checking the binocular visual field in patients with glaucoma

BACKGROUND/AIMS

Car accidents caused by drivers unaware of their visual field (VF) defects under binocular vision have become an issue. We developed a simple self-check chart (CLOCK CHART binocular edition (CCBE)) to help patients with glaucoma recognise their abnormalities in the binocular VF and evaluated its usefulness.

METHODS

The chart has four targets displayed at 10°, 15°, 20° and 25° eccentricities. The examinee gradually rotates the chart 360° clockwise. At every 30°, the examinee confirms the fixation and indicates if all four targets can be seen. This study enrolled 88 eyes of 44 patients with glaucoma (mean age, 64.4±13.1 years) and 64 eyes of 32 visually normal individuals (mean age, 32.0±8.4 years). Except the CCBE test, static VF testing using the Humphrey field analyser (HFA) Swedish Interactive Threshold Algorithm-Standard 30-2 and binocular Esterman programmes was also performed for the subjects with glaucoma.

RESULTS

VF abnormality was defined as two or more contiguous points with a sensitivity of <10 dB within the central 30°. The CCBE test had sensitivities of 85% and 82% with respect to the HFA and Esterman results, respectively. We also used the British VF standards for Group 1 (car/motorcycle) drivers, and a sensitivity of 88% was obtained for the CCBE. The chart had a specificity of 100% for the visually normal subjects.

CONCLUSION

The CCBE test enables drivers with glaucoma to notice their VF abnormalities under binocular condition. The application of this simple self-check method appears promising for occasions such as driver licensing.

Comparison of Esterman disability scores obtained using Goldmann perimetry and the Humphrey field analyzer in Japanese low-vision patients

PURPOSE

To compare the Esterman Disability Score (EDS) obtained with Goldmann perimetry (GP) testing and the Humphrey field analyzer (HFA) in low vision Japanese subjects. Subjects were also divided into groups by diagnosis to examine how disease influences EDS measurements.

METHODS

The EDS was obtained using GP (GP-EDS) and the built-in testing program of the HFA (HFA-EDS). Tests were performed within 3 months of each other. Regression analyses were used to examine the relationship between GP-EDS and HFA-EDS.

RESULTS

A total of 128 visually impaired subjects were included in this study. Subjects had low vision because of glaucoma (57 subjects), age-related macular degeneration (AMD, 17 subjects), retinitis pigmentosa (RP, 17 subjects), and other causes (37 subjects). The GP-EDS obtained was well-correlated with HFA-EDS (r = 0.87, P < 0.001) and it was possible to estimate HFA-EDS from GP-EDS. The GP-EDS was significantly lower than the HFA-EDS in eyes with glaucoma and RP. There was no significant difference between EDS values in eyes with AMD or other disease.

CONCLUSION

The GP-EDS correlated well with the HFA-EDS. However, the relationship between the EDS measured with the two different testing modalities varies by disease.

Functional visual fields: a cross-sectional UK study to determine which visual field paradigms best reflect difficulty with mobility function

OBJECTIVES

To develop an appropriate method of assessing visual field (VF) loss which reflects its functional consequences, this study aims to determine which method(s) of assessing VF best reflect mobility difficulty.

SETTING

This cross-sectional observational study took place within a single primary care setting. Participants attended a single session at a University Eye Clinic, Cambridge, UK, with data collected by a single researcher (HS), a qualified optometrist.

PARTICIPANTS

50 adult participants with peripheral field impairment were recruited for this study. Individuals with conditions not primarily affecting peripheral visual function, such as macular degeneration, were excluded from the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Participants undertook three custom and one standard binocular VF tests assessing VF to 60°, and also integrated monocular threshold 24-2 visual fields (IVF). Primary VF outcomes were average mean threshold, percentage of stimuli seen and VF area. VF outcomes were compared with self-reported mobility function assessed with the Independent Mobility Questionnaire, and time taken and patient acceptability were also considered. Receiver operating characteristic (ROC) curves determined which tests best predicted difficulty with mobility tasks.

RESULTS

Greater VF loss was associated with greater self-reported mobility difficulty with all field paradigms (R² 0.38-0.48, all P<0.001). All four binocular tests were better than the IVF at predicting difficulty with at least three mobility tasks in ROC analysis. Mean duration of the tests ranged from 1 min 26 s (±9 s) for kinetic assessment to 9 min 23 s (±24 s) for IVF.

CONCLUSIONS

The binocular VF tests extending to 60° eccentricity all relate similarly to self-reported mobility function, and slightly better than integrated monocular VFs. A kinetic assessment of VF area is quicker than and as effective at predicting mobility function as static threshold assessment.

Functional visual fields: relationship of visual field areas to self-reported function

PURPOSE

The aim of this study is to relate areas of the visual field to functional difficulties to inform the development of a binocular visual field assessment that can reflect the functional consequences of visual field loss.

METHODS

Fifty-two participants with peripheral visual field loss undertook binocular assessment of visual fields using the 30-2 and 60-4 SITA Fast programs on the Humphrey Field Analyser, and mean thresholds were derived. Binocular visual acuity, contrast sensitivity and near reading performance were also determined. Self-reported overall and mobility function were assessed using the Dutch ICF Activity Inventory.

RESULTS

Greater visual field loss (0-60°) was associated with worse self-reported function both overall (R² = 0.50; p < 0.0001), and for mobility (R² = 0.64; p < 0.0001). Central (0-30°) and peripheral (30-60°) visual field areas were similarly related to mobility function (R² = 0.61, p < 0.0001 and R² = 0.63, p < 0.0001 respectively), although the peripheral (30-60°) visual field was the best predictor of mobility self-reported function in multiple regression analyses. Superior and inferior visual field areas related similarly to mobility function (R² = 0.56, p < 0.0001 and R² = 0.67, p < 0.0001 respectively). The inferior field was found to be the best predictor of mobility function in multiple regression analysis.

CONCLUSION

Mean threshold of the binocular visual field to 60° eccentricity is a good predictor of self-reported function overall, and particularly of mobility function. Both the central (0-30°) and peripheral (30-60°) mean threshold are good predictors of self-reported function, but the peripheral (30-0°) field is a slightly better predictor of mobility function, and should not be ignored when considering functional consequences of field loss. The inferior visual field is a slightly stronger predictor of perceived overall and mobility function than the superior field.

Developing an Item Bank to Measure Quality of Life in Individuals With Glaucoma, and the Results of the Interview With Patients: The Effect of Visual Function, Visual Field Progression Rate, Medical, and Surgical Treatments on Quality of Life

PURPOSE

To construct a new item bank to measure quality of life (QOL) in glaucoma patients and to evaluate glaucoma patients' QOL using the item bank.

METHODS

An item bank of questions was generated through a literature review of QOL instruments useful for glaucoma patients. Using this item bank, a cognitive survey was performed on 203 patients with glaucoma (112 males and 91 females, 61.9±11.9 y old; mean±SD). The results were then analyzed using the Rasch analysis, and the Rasch-derived disability scores were predicted using linear modelling and the following clinical parameters: age, mean total deviation (mTD) in superior and inferior visual field (mTDsup/mTDinf), mTD progression rate, better visual acuity, worse visual acuity, number of eye drops administered per day, number of trabeculectomy procedures experienced in both eyes.

RESULTS

A total of 23 questionnaires of QOL in glaucoma patients were identified resulting in an item bank of 187 questions related to the following tasks: reading/writing, walking, going out, eating and driving (direct disability) as well as questions concerned with worry/anxiety, social participation, and physical symptoms (indirect disability). In the optimal model for direct disability, age and mTDinf were identified as significant predictors, whereas number of eye drops administered per day and number of trabeculectomy experienced were included in the optimal model for indirect disability.

CONCLUSIONS

A new item bank to measure QOL in glaucoma patients was developed and evaluated. Age and mTDinf were found to be related to direct disability while medical and surgical treatments were related to indirect disability.

Vision after trans-sylvian or temporobasal selective amygdalohippocampectomy: a prospective randomised trial

BACKGROUND

Selective amygdalohippocampectomy (SAH) is an accepted surgical procedure for treatment of pharmacoresistant mesial temporal lobe epilepsy, but it may lead to postoperative visual field deficits (VFDs). Here we present a prospective randomised trial comparing the postoperative VFDs after either a trans-sylvian or temporobasal approach for SAH.

METHOD

Forty-eight patients were randomly assigned to trans-sylvian (n = 24) or temporobasal (n = 24) SAH. Postoperative VFD were quantitatively evaluated using automated static and kinetic perimetry. In 24 cases, diffusion tensor imaging-based deterministic fibre-tracking of the optic radiation was performed. The primary endpoint was absence of postoperative VFD. The secondary endpoint was seizure outcome and driving ability.

RESULTS

Three patients (13 %) from the trans-sylvian group showed no VFD, compared to 11 patients (46 %) from the temporobasal group without VFD (p = 0.01, RR = 3.7; CI = 1.2-11.5). Fifteen patients from each group (63 %) became completely seizure-free (ILAE1). Among those seizure-free cases, five trans-sylvian (33 %) and ten temporobasal (66 %) patients could apply for a driving licence (NNT = 3) when VFDs were considered. Although the trans-sylvian group experienced more frequent VFDs, the mean functional visual impairment showed a tendency to be less pronounced compared with the temporobasal group. DTI-based tracking of the optic radiation revealed that a lower distance of optic radiation to the temporal base correlated with increased rate of VFD in the temporobasal group.

CONCLUSIONS

Temporobasal SAH shows significantly fewer VFDs and equal seizure-free rate compared with the trans-sylvian SAH. However, in patients in whom the optic radiation is close to the temporal base, the trans-sylvian approach may be a preferred alternative.

Visual disability and quality of life in glaucoma patients

Glaucoma is an optic neuropathy that can result in progressive and irreversible vision loss, thereby affecting quality of life (QoL) of patients. Several studies have shown a strong correlation between visual field damage and visual disability in patients with glaucoma, even in the early stages of the disease. Visual impairment due to glaucoma affects normal daily activities required for independent living, such as driving, walking, and reading. There is no generally accepted instrument for assessing quality of life in glaucoma patients; different factors involved in visual disability from the disease are difficult to quantify and not easily standardized. This chapter summarizes recent works from clinical and epidemiological studies, which describe how glaucoma affects the performance of important vision-related activities and QoL.

The correlation between glaucomatous visual field loss and vision-related quality of life

PURPOSE

To evaluate the vision-related quality of life (QoL) of glaucoma patients in terms of the correlation between visual field (VF) loss and National Eye Institute Visual Functioning Questionnaire-39 (NEI VFQ-39) survey.

MATERIALS AND METHODS

A total of 244 glaucoma patients were examined with monocular Humphrey 24-2 central full threshold and Esterman binocular VF tests. Patients were grouped according to their monocular VFs done by Advanced Glaucoma Intervention Study (AGIS) classification and Esterman binocular VF efficiency scores. NEI VFQ-39 was applied for the evaluation of vision-related QoL.

RESULTS

NEI VFQ-39 subscales and total scores were evaluated and the highest mean average values were in "color vision" (92.00±16.59) and "social functioning" (90.74±15.98). The lowest mean average values were in "general health" (54.76±18.86) and "general vision" (66.03±17.59). All the subscales except "general health" and "ocular pain" showed positive correlations with the monocular and Esterman binocular VF groupings. Pearson correlation analysis between NEI VFQ-39 subscales and the AGIS VF classification-based groups indicated that the subscales had statistically significant negative correlations except the "general health" (r=-0.151, P=0.018) and "ocular pain" (r=-0.048, P=0.455). The highest correlation with AGIS VF classification was in "driving" (r=-0.477, P=0.001) and "general vision" (r=-0.446, P=0.000) subscales. There was statistically significant correlation between NEI VFQ-39 subscales and Esterman binocular VF groups except "general health" (r=-0.064, P=0.318) and "ocular pain" (r=-0.062, P=0.337). The highest negative correlation was in "distant activities" (r=-0.522, P=0.000) and the lowest negative correlation was in "color vision" (r=-0.416, P=0.000) subscales. The highest correlation between binocular distant and binocular near-visual acuities was in "distant activities" and the lowest correlation was in "role difficulties" subscales.

CONCLUSIONS

There is statistically significant correlation between the glaucoma patients' VF loss and the vision-related QoL. The evaluation of self-reported vision status in glaucoma patients may be a guide for the rehabilitation of their disabilities in vision-related daily activities.

Identifying content for the glaucoma-specific item bank to measure quality-of-life parameters

PURPOSE

Patient-reported outcomes (PROs) have become essential clinical trial end points. However, a comprehensive, multidimensional, patient-relevant, and precise glaucoma-specific PRO instrument is not available. Therefore, the purpose of this study was to identify content for a new, glaucoma-specific, quality-of-life (QOL) item bank.

METHODS

Content identification was undertaken in 5 phases: (1) identification of extant items in glaucoma-specific instruments and the qualitative literature; (2) focus groups and interviews with glaucoma patients; (3) item classification and selection; (4) expert review and revision of items; and (5) cognitive interviews with patients.

RESULTS

A total of 737 unique items (extant items from PRO instruments, 247; qualitative articles, 14 items; focus groups and semistructured interviews, 476 items) were identified. These items were classified into 10 QOL domains. Four criteria (item redundancy, item inconsistent with domain definition, item content too narrow to have wider applicability, and item clarity) were used to remove and refine the items. After the cognitive interviews, the final minimally representative item set had a total of 342 unique items belonging to 10 domains: activity limitation (88), mobility (20), visual symptoms (19), ocular surface symptoms (22), general symptoms (15), convenience (39), health concerns (45), emotional well-being (49), social issues (23), and economic issues (22).

CONCLUSIONS

The systematic content identification process identified 10 QOL domains, which were important to patients with glaucoma. The majority of the items were identified from the patient-specific focus groups and semistructured interviews suggesting that the existing PRO instruments do not adequately address QOL issues relevant to individuals with glaucoma.

Areas of the visual field important during reading in patients with glaucoma

PURPOSE

To determine the areas of the binocular visual field (VF) associated with reading speed in glaucomatous patients with preserved visual acuity (VA).

MATERIALS AND METHODS

Fifty-four patients with glaucoma (mean age ± standard deviation 70 ± 8 years) and 38 visually healthy controls (mean age 66 ± 9 years) had silent reading speeds measured using non-scrolling text on a computer setup. Participants completed three cognitive tests and tests of visual function, including the Humphrey 24-2 threshold VF test in each eye; the results were combined to produce binocular integrated VFs (IVFs). Regression analyses using the control group to correct for cognitive test scores, age and VA were conducted to obtain the IVF mean deviation (MD) and total deviation (TD) value from each IVF test location. Concordance between reading speed and TD, assessed using R (2) statistics, was ranked in order of importance to explore the parts of the IVF most likely to be linked with reading speed.

RESULTS

No significant association between IVF MD value and reading speed was observed (p = 0.38). Ranking individual thresholds indicated that the inferior left section of the IVF was most likely to be associated with reading speed.

CONCLUSIONS

Certain regions of the binocular VF impairment may be associated with reading performance even in patients with preserved VA. The inferior left region of patient IVFs may be important for changing lines during reading.

Visual Field Progressive Rate in Normal Tension Glaucoma Before and After Trabeculectomy: A Subfield-Based Analysis

PURPOSE

To compare pretrabeculectomy and posttrabeculectomy progression rates in normal-tension glaucoma in 6 subfields of the central 30 visual field.

DESIGN

A retrospective study.

METHODS

Clinical records of 34 patients with normal-tension glaucoma (12 males and 22 females) with progressive visual field loss undergoing successful trabeculectomy were studied. The time course of the mean deviation (MD) and mean of total deviation in the superior/inferior arcuate, paracentral, and cecocentral subfields were analyzed using a linear mixed-effects model.

RESULTS

Patients' age, intraocular pressure (IOP), MD, and pretrabeculectomy and posttrabeculectomy follow-up averaged 57.7 ± 9.6 years, 15.7 ± 1.7 mm Hg, -12.7 ± 5.5 dB, and 4.6 ± 1.5 and 5.7 ± 1.2 years, respectively. Average IOP was lowered by 6.1 ± 3.3 to 10.3 ± 2.7 mm Hg (5-14 mm Hg) over the postoprerative period with MD change rate of -0.25 dB/y (P < 0.003), which was slower (P < 0.001) than the preoperative one (-0.70 dB/y). The preoperative mean of total deviation change rate (-0.31 to -1.35 dB/y) improved postoperatively in the superior and inferior paracentral subfields (P < 0.001), whereas it remained unchanged in the inferior cecocentral/arcuate subfields (P > 0.10). The postoperative rate of progression showed no significant variation in these subfields.

CONCLUSIONS

The rate of progression significantly varied among the 6 subfields preoperatively. It was significantly slowed down in the superior subfields by surgical IOP reduction, but not in the inferior cecocentral/arcuate subfields.

Pre-validation methods for developing a patient reported outcome instrument

Background

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

Methods

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

Results

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

Conclusions

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

Patient-reported outcomes (PRO's) in glaucoma: a systematic review

The aim of this review was to summarize literature in view of patient-reported outcome (PRO) instruments for glaucoma and provide guidance on how outcomes are best assessed based on evidence about their content and validity. A systematic literature review was performed on papers describing the developmental process and/or psychometric properties of glaucoma or vision-specific PRO-instruments. Each of them was assessed on their adherence to a framework of quality criteria. Fifty-three articles were identified addressing 27 PRO-instruments. In all, 18 PRO's were developed for glaucoma and 9 for diverse ophthalmologic conditions. Seven instruments addressed functional status, 11 instruments quality of life and 9 instruments disease and treatment-related factors. Most of the instruments demonstrated only partially adherence to predefined quality standards. The tools for assessing functional status were of poor quality, while the Glaucoma Quality of Life Questionnaire and the Vision Quality of Life Index were well-developed QoL measures, yet only validated using classical techniques. The Rasch-scaled QoL-tools, IVI and VCM1 need to improve their item-content for glaucoma patients. The questionnaires to measure adherence should improve their validity and the Treatment Satisfaction Survey for Intra Ocular Pressure pops out as the highest quality tool for measuring topical treatment side effects. This review revealed that most PRO-instruments demonstrated poor developmental quality, more specifically a lack of conceptual framework and item generation strategies not involving the patients' perspective. Psychometric characteristics were mostly tested using classical validation techniques.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Visual fields in patients with multifocal intraocular lens implants and monovision: an exploratory study

PURPOSE

To assess the difference in binocular visual fields (VFs) in patients who underwent bilateral cataract surgery with either multifocal (MF; Tecnis ZM900, AMO) intraocular lenses (IOLs) or monofocal IOLs with powers adjusted to give monovision (MV; Akreos AO, Bausch&Lomb).

SETTING

St George's & Moorfields Eye Hospital, London.

METHODS

Prospective exploratory study. Binocular Esterman VFs (Humphrey Field Analyser II) were compared between 10 participants with MV and 16 participants with MF IOLs. The dominant eye in MV participants had 0 to -0.50DS and the non-dominant eye had between -1.0DS and -1.5DS. Best-corrected Snellen visual acuity for all 52 eyes was six out of nine or better. The main outcome measure was Esterman Efficiency Score. Incidence of suboptimal VF results (≥1 Unseen Locations--ULs) and mean testing times in the two groups were compared.

RESULTS

There was no statistically significant difference in the incidence of suboptimal VF results in these two groups (P=0.662). Test durations in the two groups were not significantly different (P=0.650). However, 3/10 MV plots (33%) had markedly suboptimal right hemi-fields (distance-dominant eye) compared with 0/15 MF plots. Additionally, the MV group accounted for 79% of total ULs (20/29) and all these ULs were distributed in areas outside or bordering the true binocular VFs.

CONCLUSIONS

All included VFs met the UK driving standards criteria. The pattern of VF defects encountered in the MV group is of interest because the majority of ULs (13/20; 65%) corresponded to the monocular VFs of the distance-dominant eye.

Reliability and validity of abbreviated surveys derived from the National Eye Institute Visual Function Questionnaire: the study of osteoporotic fractures

PURPOSE

To test the reliability and validity of questionnaires shortened from the National Eye Institute 25-item Vision Function Questionnaire (NEI VFQ-25).

DESIGN

Cross-sectional, multicenter cohort study.

METHODS

Reliability was assessed by Cronbach alpha coefficients. Validity was evaluated by studying the association of vision-targeted quality-of-life composite scores with objective visual function measurements. A total of 5482 women between the ages of 65 and 100 years participated in the year-10 clinic visit in the Study of Osteoporotic Fractures (SOF). A total of 3631 women with complete data were included in the visual acuity (VA) and visual field (VF) analyses of the 9-item NEI VFQ (NEI VFQ-9), which is defined for those who care to drive, and a total of 5311 women with complete data were included in the VA and VF in the analyses of the 8-item NEI VFQ (NEI VFQ-8). To assess differences in prevalent eye diseases, which were ascertained for a random sample of SOF participants, 853 and 1237 women were included in the NEI VFQ-9 and the NEI VFQ-8 analyses, respectively.

RESULTS

The Cronbach alpha coefficient for the NEI VFQ-9 scale was 0.83, and that of the NEI VFQ-8 was 0.84. Using both questionnaires, women with VA worse than 20/40 had lower composite scores compared with those with VA of 20/40 or better (P < .001). Participants with mild, moderate, and severe binocular VF loss had lower composite scores compared with those with no binocular VF loss (P < .001). Compared with women without chronic eye diseases in both eyes, women with at least 1 chronic eye disease in at least 1 eye had lower composite scores.

CONCLUSIONS

Both questionnaires showed high reliability across items and validity with respect to clinical markers of eye disease. Future research should compare the properties of these shortened surveys with those of the NEI VFQ-25.

Visual field loss and risk of fractures in older women

OBJECTIVES

To evaluate the associations between visual field loss and nonspine fractures.

DESIGN

Prospective cohort study.

SETTING

Community.

PARTICIPANTS

Four thousand seven hundred seventy-three community-dwelling white and African-American women aged 65 and older with no previous history of hip fracture at the time of recruitment.

MEASUREMENTS

Radiographically confirmed hip and nonspine, nonhip fractures identified from September 1997 to April 2008. Visual field loss was measured using a Humphrey Field Analyzer suprathreshold screening test of the peripheral and central vision of each eye and was classified into an ordinal rating of no, mild, moderate, or severe binocular visual field (BVF) loss.

RESULTS

For hip and nonspine, nonhip fractures and in unadjusted and covariate-adjusted analyses, the highest incidence of fractures was seen in women with the most-severe BVF loss. In covariate-adjusted analysis, women with mild, moderate, and severe BVF loss had a 49% (hazard ratio (HR)=1.49, 95% confidence interval (CI)=1.18-1.88), 25% (HR=1.25, 95% CI=0.87-1.80), and 66% (HR=1.66, 95% CI=1.19-2.32) greater risk, respectively, for hip fractures than women without BVF loss. Similarly, women with mild visual field loss had a 12% (HR=0.88, 95% CI=0.75-1.04) lower risk for nonspine, nonhip fractures, whereas women with moderate and severe visual field loss had a 18% (HR=1.18, 95% CI=0.92-1.52) and 59% (HR=1.59, 95% CI=1.24-2.03) greater risk of nonspine, nonhip fractures than women without BVF loss.

CONCLUSION

BVF loss is independently associated with hip and nonspine, nonhip fractures in older female volunteers.

Effect of combat eye protection on field of view among active-duty U.S. military personnel

BACKGROUND

This study was conducted to determine if ballistic protective eyewear issued to U.S. military service members causes functional blind spots in the visual field. The study also investigated whether the use of corrective lenses with these devices contributes to defects in the visual field.

METHODS

Visual fields were measured using the Esterman Binocular Function test on the Humphrey Field Analyzer. Each subject performed the test with no devices and then repeated the test while wearing several combinations of ballistic eyewear (spectacles or goggles) and prescription correction. Mean differences in Esterman scores between each device and baseline were analyzed.

RESULTS

The spectacle devices did not show significant differences in mean Esterman scores from baseline. The goggle systems did show significant reductions in the peripheral field (P < 0.0001). The use of prescription correction with combat eye protection increased the number of missed points in the periphery by an average of 12.2% compared with ballistic devices alone (P < 0.0001).

CONCLUSION

The use of ballistic protective goggles and prescription lens inserts with military combat eye protection causes a significant reduction in the peripheral field. Service members should be educated to replace eye movements with head movements when scanning the periphery.

Modified Bahasa Malaysia version of VF-14 questionnaire: assessing the impact of glaucoma in rural area of Malaysia

PURPOSE

To evaluate the functional impairment of glaucoma patients, using a modified Bahasa Malaysia version of VF-14 questionnaire, and to correlate the score with the severity of the disease.

METHODS

One-to-one interview by trained interviewers was conducted on glaucoma patients seen in the eye clinic of Hospital Universiti Sains Malaysia, using a modified validated Bahasa Malaysia version of VF-14 questionnaire. The severity of glaucoma was determined based on the better-eye Advanced Glaucoma Intervention Study Scale (AGIS) score of visual field analysis on the latest most reliable visual field. The literacy rate, living situation, better-eye visual acuity and lens status were also documented.

RESULTS

A total of 110 glaucoma patients were recruited (54.5% primary open-angle glaucoma, 21.8% primary angle-closure glaucoma, 19.2% normotensive glaucoma and 4.5% pseudoexfoliative glaucoma) and majority with bilateral involvement. Based on the better-eye AGIS score, 41.5% were in advanced stage, 29.1% moderate and 29.1% mild. There was a significant association between VF-14 scoring with the better-eye AGIS score (r =-0. 579, P < 0.001), age (r = -0.313, P = 0.000) and better-eye visual acuity (r = -0.752, P = 0.000). Based on the multivariate analysis, there was a significant association of the questionnaire score and better-eye AGIS score (P < 0.001).

CONCLUSION

The Bahasa Malaysia version of modified VF-14 questionnaire is a useful tool in quantifying quality of life among glaucoma patients in rural area with high illiteracy rate and provides moderate correlation with severity of the disease. Customization of quality of life questionnaire according to custom and culture of the community will provide better insight to the functional impairment of glaucoma patients.

Binocular visual-field loss increases the risk of future falls in older white women

OBJECTIVES

To examine the relationship between binocular visual field loss and the risk of incident frequent falls in older white women.

DESIGN

A multicenter, prospective cohort study.

SETTING

Four clinic centers within the United States in Baltimore, Maryland; Minneapolis, Minnesota; Portland, Oregon; and the Monongahela Valley, Pennsylvania.

PARTICIPANTS

Four thousand seventy-one community-dwelling white women aged 70 and older participating in the Study of Osteoporotic Fractures.

MEASUREMENTS

Primary outcome was incident frequent falls, defined as two or more falls within 1 year. Primary risk factors were binocular visual field loss, distance visual acuity in the better eye, and contrast sensitivity at low spatial frequency in the better eye.

RESULTS

Of 4,071 women, 409 (10%) had severe binocular visual field loss at the eye examination, and 643 (16%) experienced frequent falls within 1 year after their eye examination. Severe binocular visual field loss was significantly associated with frequent falls when adjusting for age, study site, and cognitive function (odds ratio=1.50, 95% confidence interval=1.11-2.02). The data showed a trend for increasing odds of two or more falls with greater binocular visual field loss (P<.001). In older white women with severe binocular visual field loss, 33.3% of frequent falls were attributable to visual field loss.

CONCLUSION

Women with binocular visual field loss are at greater risk of future frequent falls. Screening for binocular visual field loss may identify individuals at high risk of falling.

Categorizing the stage of glaucoma from pre-diagnosis to end-stage disease

PURPOSE

To provide a reliable, comprehensive staging system to assess glaucoma stage in the absence of an universally accepted glaucoma staging system (GSS) on the basis of visual field results.

DESIGN

Literature review and GSS adaptation.

METHODS

After a review of published GSSs was conducted, the Bascom Palmer (Hodapp-Anderson-Parrish) GSS was selected as an appropriate platform for a retrospective GSS on the basis of visual fields. The system was modified by a panel of glaucoma specialists, and additional modifications were made after pilot testing to cover the full range of disease progression, from preglaucoma diagnosis to complete blindness; the ordered stages reflect the typical progression of glaucoma.

RESULTS

The GSS is comprised of six ordered stages and is on the basis of the Humphrey visual field. The completed GSS was validated by reviewing patient charts from 12 US glaucoma centers.

CONCLUSIONS

The GSS allows accurate staging of 100% of glaucoma on the basis of visual fields and other data, enabling evaluation of disease progression and resource utilization at various glaucoma stages. Additionally, treatment costs may be assigned to determine cost-effectiveness of treatment. Research utilizing the GSS has found that cost of care increases with increasing disease severity. The GSS may be used as the basis for creating treatment guidelines, which have the potential to delay glaucoma progression and lower treatment costs.

Direct costs of glaucoma and severity of the disease: a multinational long term study of resource utilisation in Europe

BACKGROUND

Resource utilisation and direct costs associated with glaucoma progression in Europe are unknown. As population progressively ages, the economic impact of the disease will increase.

METHODS

From a total of 1655 consecutive cases, the records of 194 patients were selected and stratified by disease severity. Record selection was based on diagnoses of primary open angle glaucoma, glaucoma suspect, ocular hypertension, or normal tension glaucoma; 5 years minimum follow up were required. Glaucoma severity was assessed using a six stage glaucoma staging system based on static threshold visual field parameters. Resource utilisation data were abstracted from the charts and unit costs were applied to estimate direct costs to the payer. Resource utilisation and estimated direct cost of treatment, per person year, were calculated.

RESULTS

A statistically significant increasing linear trend (p = 0.018) in direct cost as disease severity worsened was demonstrated. The direct cost of treatment increased by an estimated 86 for each incremental step ranging from 455 euro per person year for stage 0 to 969 euro per person year for stage 4 disease. Medication costs ranged from 42% to 56% of total direct cost for all stages of disease.

CONCLUSIONS

These results demonstrate for the first time in Europe that resource utilisation and direct medical costs of glaucoma management increase with worsening disease severity. Based on these findings, managing glaucoma and effectively delaying disease progression would be expected to significantly reduce the economic burden of this disease. These data are relevant to general practitioners and healthcare administrators who have a direct influence on the distribution of resources.

[Proposed scoring system for assessment of functional impairment due to visual field defects]

INTRODUCTION

The purpose of the study is the development of a scoring system for the assessment of functional impairment due to visual field defects, based on the Esterman grid, but adapted to the existing system in the Federal Republic of Germany.

METHODS

The score areas and the evaluation rules were altered iteratively, until the functional score by the new system matched as much as possible the score obtained from the existing system of geometrical defect patterns.

RESULTS

The visual field is divided into 100 score areas, which are smaller in the visual field center and in its lower region, respectively. The areas inside the reference isopter are counted and taken as total function in percent. Areas with monocular perception are rated with 3/4 points. Functional impairment is defined as the difference of total function to 100%. For 9 of 20 defect patterns, the functional scores are equal. Another six patterns differ by 1-4%. The remaining 5 of 20 patterns differ by 6-8% in either direction.

CONCLUSION

The new system is easier to apply, more consistent, and covers irregular defect patterns. The level of functional impairment is nearly identical with both systems. A transition to the scoring system would considerably increase the certitude and the quality of assessment especially in difficult cases.

Integrated visual fields: a new approach to measuring the binocular field of view and visual disability

BACKGROUND

We have developed a method of quantifying the central binocular visual field by merging results from monocular fields (Integrated visual field). This study aims to compare the new measure with the binocular Esterman visual field test in identifying patients with self-reported visual disability.

METHODS

Forty-eight patients with glaucoma each recorded Humphrey 24-2 fields for both eyes and an Esterman on the same day, and each completed a binary forced-choice questionnaire relating to perceived visual disability. Computer software merged sensitivity values from monocular fields to generate an integrated visual field and a related score of the number of defects at the <10 dB and <20 dB level. Receiver operating characteristic (ROC) analysis was used to compare the integrated visual field score and the Esterman disability score with individual responses to the questions on perceived difficulty with visual tasks.

RESULTS

Comparison of areas under ROC curves revealed that a score based on the integrated visual field was generally better (median area: 0.79) than Esterman scores (median area: 0.70) in classifying patients with or without a self-reported perceived difficulty with visual tasks.

CONCLUSIONS

The integrated visual field offers a rapid assessment of a glaucoma patient's binocular visual field without extra perimetric testing. As compared to an actual binocular field test (Esterman), the integrated visual field provides a better prediction of a glaucoma patient's perceived inability to perform certain visual tasks.

Esterman binocular scoring in amblyopia

The Esterman binocular visual field test was performed on 24 amblyopic subjects and 10 normal subjects. No correlation was found between the evaluated clinical parameters and Esterman scores in the patients with amblyopia. The Esterman score may not properly reflect the actual binocular disability in amblyopia.

Associations between glaucomatous visual field loss and participation in activities of daily living

PURPOSE

This study investigated the association between visual field loss and participation in daily activities in individuals with glaucoma.

METHODS

Seventy-nine patients were recruited from the Royal Victorian Eye and Ear Hospital. Visual fields were assessed using the Esterman binocular visual field tests and participation in daily activities was assessed using the Impact of Vision Impairment (IVI) questionnaire. Visual acuity and contrast sensitivity were also measured.

RESULTS

There was no independent relationship between visual field loss and IVI score (r = -0.20; P = 0.09), except for the mobility domain (r = 0.25; P = 0.03). Mobility was the most affected domain of the IVI (mean = 1.2). Over a quarter of the patients reported experiencing moderate to severe restriction with mobility activities despite relatively minor binocular field loss.

CONCLUSION

Mobility is the area in which glaucoma patients encounter difficulties even when the visual field and visual acuity are relatively good. Questions related to mobility could be asked to identify those patients who need rehabilitation.

Visual function, disability, and psychological impact of glaucoma

PURPOSE OF REVIEW

This report briefly reviews recent instruments designed to test the visual function and quality of life of patients with glaucoma.

RECENT FINDINGS

Several investigators have examined the functional status and vision-related quality of life among patients with glaucoma. These studies have shown that patients with glaucoma experience diminished visual function and poorer quality of life.

SUMMARY

Because glaucoma and its treatment, either medical or surgical, can affect global quality of life as well as vision-related functioning, the assessment of both general and visual system health status is relevant.

Quality of life in glaucoma and its relationship with visual function

PURPOSE

The aims of this study were (a) to explore patients self-reported visual disability resulting from glaucoma by means of a questionnaire developed for this purpose; (b) identify activities strongly associated with a measure of visual field loss, (c) to quantify different psychophysical aspects of visual function; (d) to assess the relationship between objective measures of visual function and patients' perception of their vision-related quality of life.

PATIENTS AND METHODS

Three groups of glaucoma patients (n = 47) with mild (n = 18), moderate (n = 19), and severe visual field loss (n = 10) and a group of normal controls (n = 19) underwent a comprehensive clinical examination, completed a questionnaire and, on a separate visit, performed a number of psychophysical tests of visual function.

MAIN OUTCOME MEASURES

Questionnaire responses (vision-related quality of life, general health and psychosocial variables), visual acuity, visual fields, Esterman binocular disability scores, contrast sensitivity, critical flicker frequency, color vision, dark adaptation, glare disability (brightness acuity), and stereoacuity scores were measured.

RESULTS

Fifteen of the 50 questions were noted to have a strong significant relationship with a measure of visual field loss and were included in a new questionnaire scale, the Glaucoma Quality of Life - 15 (GQL-15). The scale validity showed a significant correlation with perimetric mean deviation (MD) values (r = -0.6; P < 0.0001), the reliability of the scale was high (Cronbach alpha = 0.95), and test-retest reliability of the questionnaire was strong (r = 0.87). An overall statistically significant decrease in performance-related quality of life was noted between normal subjects and all groups of glaucoma patients. A significant relationship was found between the scale questionnaire summary performance measure and a number of psychophysical tests: Pelli-Robson contrast sensitivity (r = -0.45, P < 0.001), glare disability (r = -0.41, P < 0.001), Esterman binocular visual field test (r = -0.39, P < 0.001), dark adaptation (r = 0.34, P = 0.007), and stereopsis (r = 0.26, P = 0.04).

CONCLUSION

Perceived visual disability relating to certain tasks (particularly involving dark adaptation and disability glare, activities demanding functional peripheral vision such us tripping over and bumping into objects and outdoor mobility tasks) was significantly associated with the severity of binocular visual field loss. As a result, a new glaucoma-specific questionnaire scale with good performance characteristics is presented in this study. The difficulties encountered by patients in everyday life (as measured with the questionnaire) were also mirrored in their performance on a number of psychophysical tests, especially contrast sensitivity, glare disability, Esterman binocular visual field test, and dark adaptation.

The relationship between visual disability and visual field in patients with glaucoma

PURPOSE

To evaluate the relationship between visual disability and the remaining visual field in glaucoma patients.

DESIGN

Prospective noncomparative survey.

PARTICIPANTS

One hundred forty-seven Japanese patients with glaucoma were examined.

METHODS

Using a previously developed questionnaire, we assessed the relationship between visual disability indices and both the visual field examined using program 30-2 of the Humphrey Field Analyzer and visual acuity.

MAIN OUTCOME MEASURES

Pearson's correlation coefficients between visual disability indices and the 22 visual field and 2 visual acuity measurements were calculated. Multiple regression analysis with stepwise variable selection identified factors significantly contributing to visual disability.

RESULTS

We identified a significant correlation between visual disability and both the visual field and visual acuity measurements collected. Of the factors examined, retinal sensitivity in the lower hemifield within 5 degrees of the fixation and visual acuity in the better eye significantly contributed to all the item and total disability indices (DIs), measurements of the degree of visual disability as evaluated by the questionnaire; visual acuity in the worse eye contributed to two of the seven item DIs, as well as the total DI. The R value for total DI (R = 0.87, P < 0.0001) indicated that approximately 76% of the visual disability could be explained by these factors.

CONCLUSIONS

The Japanese glaucoma patients' visual disability is explained primarily by retinal sensitivity in the lower hemifield within 5 degrees of the fixation and visual acuity in the better eye and secondarily by visual acuity in the worse eye.

Quality of life of elderly Japanese patients with glaucoma

To evaluate the quality of life (QOL) of elderly Japanese glaucoma patients, we performed a survey of 114 outpatients of a university eye clinic aged from 47 to 86 years. We examined 110 cases using one-way anova, Bonferroni's multiple comparison, non-parametric Mann-Whitney U-test and Pearson's correlation coefficient analysis. The group with better traditional visual measures had better QOL than the group with worse visual acuity. In the elderly groups of patients, the loss of hopes for future life and its consequences caused greater reduction in QOL than did the symptoms of glaucoma. The reliability of our questionnaire was high as determined using alpha-coefficients of Cronbach reliability analysis. Our questionnaire was reliable and useful for the assessment of QOL of elderly Japanese glaucoma patients.

Impact of graphical user interface screen features on computer task accuracy and speed in a cohort of patients with age-related macular degeneration

PURPOSE

To investigate the impact of graphical user interface screen features on computer task performance in patients with age-related macular degeneration (AMD).

DESIGN

Interventional case series.

METHODS

Eighteen patients with visual impairment due to AMD were recruited from the Bascom Palmer Eye Institute Low Vision Clinic. Each patient underwent evaluation of visual acuity using the Early Treatment Diabetic Retinopathy Study protocol, contrast sensitivity using a Pelli-Robson chart, binocular simultaneous visual field using the Esterman program on an automated perimeter, and color vision using Farnsworth D-15. Each subject then completed computer icon identification tasks while the following screen features of the graphical user interface were varied: size of icons displayed, icon set size (number of icons displayed), and background color. Each patient performed all 125 computer tasks with each of five icon sizes (9.2 mm, 14.6 mm, 23.2 mm, 36.8 mm, 58.3 mm), each of five icon set sizes (2, 3, 4, 5, 6), and each of five different background colors (black, white, red, green, blue) in a randomly ordered fashion. Relationships between computer task performance (accuracy and speed) and graphical user interface screen features were studied.

RESULTS

Icon size and icon set size are significantly associated with computer task accuracy (P <.001), whereas background color is not a significant predictor of task accuracy (P =.63). The impact of icon size on accuracy is nonlinear, with the data indicating that no additional improvement in accuracy is associated with increasing the icon size beyond 23.2 mm. The impact of icon set size on accuracy is linear, with a smaller icon set size significantly associated with greater computer accuracy. A larger icon size is significantly associated with a shorter time to task completion (P =.001); this relationship is largely linearly related to icon size. There was no significant impact of background color (P =.11) or set size (P =.37) on time to task completion.

CONCLUSIONS

Modifications of graphical user interface design may permit improved computer task performance among patients with visual impairment due to AMD.

Myopia and advanced-stage open-angle glaucoma

OBJECTIVE

To investigate the effect of myopic refraction on the central visual field in patients with advanced open-angle glaucoma (OAG).

DESIGN

Multicenter cross-sectional study.

PARTICIPANTS

Three hundred thirteen OAG eyes (176 eyes of 176 primary open-angle glaucoma [POAG] patients and 137 eyes of 137 normal-tension glaucoma [NTG] patients) with clear ocular media and a mean deviation (MD) <-15 dB. Patients with a recorded maximum intraocular pressure (IOP) of 22 mmHg or greater were classified as POAG, and those with an IOP of 21 mmHg or less were classified as NTG.

METHODS

Multiple regression analysis was used to study the influence of refraction on 12 central test points of the C30-2 Humphrey program, and the differences in visual field defects between POAG and NTG eyes were examined using logistic discriminant analysis. In the multiple regression analysis, total deviation (TD) of the 12 test points was graded and used as the dependent variable, and MD and the spherical equivalent refraction were the explanatory variables. In the logistic discrimination analysis, TD, MD, and refraction were covariants that determined the OAG subtypes.

MAIN OUTCOME MEASURES

TD values of the 12 central test points (C30-2 program).

RESULTS

Higher myopic refraction was significantly associated with more damage at a point just temporal and inferior to the fixation point in POAG eyes, whereas it was significantly associated with less damage at test points just temporal and superior to the fixation point in NTG eyes. After correcting for the influence of refraction, POAG eyes had significantly more damage at a test point just temporal and inferior to the fixation point, whereas NTG eyes had significantly more damage at those test points nasal and inferior to the fixation point.

CONCLUSIONS

High myopia constitutes a threat to the remaining lower cecocentral visual field and is one of the factors that interfere with the quality of vision in advanced OAG with high IOP but not low IOP.

Glaucoma patients' assessment of their visual function and quality of life

PURPOSE

To determine how glaucoma and glaucoma suspect patients' rating of their vision correlates with Esterman binocular visual field testing and other visual function tests.

METHODS

One hundred ninety-one glaucoma patients and 46 glaucoma suspect patients underwent binocular visual field testing and evaluated their vision using the linear rating scale and time-tradeoff utility tests, the National Eye Institute Visual Functional Questionnaire (NEI VFQ-25), and the Short Form 36 (SF-36) quality-of-life instruments.

RESULTS

The mean Esterman score was 88.2 +/- 17.4 for the glaucoma subjects and 95.2 + 6.9 for glaucoma suspect subjects (maximum score 100). On a scale from 0 (blind) to 100 (ideal), the mean rating of vision for glaucoma patients and glaucoma suspect patients was 74.8 +/- 17.3 and 78.9 +/- 18.5, respectively. The Esterman test correlated moderately with the overall NEI VFQ-25 score (partial correlation coefficient (PCC) = 0.32, P = 0.001), but only weakly with the linear rating scale (PCC = 0.17, P = 0.02), and the time-tradeoff (PCC = 0.14, P = 0.06).

CONCLUSION

Utility values that glaucoma and glaucoma suspect patients assign to their vision do not correlate well with Esterman results. A challenge for the future is the design of clinical tests of vision that better correlate with patient perceptions.

Impact of visual function on computer task accuracy and reaction time in a cohort of patients with age-related macular degeneration

PURPOSE

To investigate the impact of visual function parameters on computer task performance in patients with age-related macular degeneration (AMD).

DESIGN

Interventional case series.

METHODS

Eighteen patients with visual impairment due to age-related macular degeneration underwent evaluation of visual acuity using the Early Treatment Diabetic Retinopathy Study protocol, contrast sensitivity using a Pelli-Robson chart, binocular simultaneous visual field using the Esterman program on an automated perimeter, and color vision using Farnsworth D-15. Each subject then completed 125 computer icon identification tasks. Relationships between computer task performance (accuracy and speed) and visual function parameters (visual acuity, contrast sensitivity, visual field, and color vision) were analyzed.

RESULTS

Visual acuity and contrast sensitivity in the better eye, weighted average contrast sensitivity, and color vision defects are significantly associated with computer task accuracy. Visual acuity in the better eye, weighted average visual acuity, and color vision defects are significantly associated with performance speed. Visual function parameters and clinical features significantly associated with computer task accuracy in a multiple regression model include weighted average contrast sensitivity (P = 0.001), protan color vision defect (P = 0.002), cataract severity in the better-seeing eye (P = 0.036), and geographic atrophy outside the central macula (P = 0.046). Visual function parameters and clinical features significantly associated with computer task speed in a multiple regression model include color vision defects (deutan, P < 0.001; protan, P < 0.001) and gender (P = 0.05).

CONCLUSIONS

Among this cohort of patients with AMD, visual acuity, contrast sensitivity, and color vision defects are significant predictors of computer task performance. Visual function parameters of the better eye played a more significant role than parameters of the worse eye, and contrast sensitivity is the most significant predictor of computer task accuracy.

Quality of life in patients with early, moderate and advanced glaucoma

PURPOSE

To evaluate the quality of life in glaucomatous patients using two different questionnaires: the medical outcomes study 36-item short-form health survey (MOS SF-36) and Viswanathan et al's questionnaire and to compare these two questionnaires.

METHODS

Seventy-seven patients with glaucoma were consecutively selected. Two force-choice questionnaires were administered to each patient. Viswanathan et al's questionnaire was related to visual disability and the second was related to the quality of life from the MOS 36-item short-form health survey. Both questionnaires were evaluated among all the considered patients and the results were compared. Then the questionnaire which did the best evaluation was used to test the quality of life in three different subgroups based on the mean deviation of the worse eye. Mann-Whitney non parametric test and Spearman's r coefficient were used and a P value less than 0.05 was considered to be statistically significant. A linear regression model was used.

RESULTS

In the entire group (n = 77) the Mean Deviation (MD) was -6.5 +/- 6.8 dB (mean +/- standard deviation) and Corrected Pattern Standard Deviation (CPSD) was 4.7 +/- 4.1 dB. The score of the Viswanathan et al's questionnaire was 8.3 +/- 2.4, while MOS SF-36 score ranged from 60.5% to 100% (mean score %). A significant (P < 0.0001) correlation was found between the score of the Viswanathan et al's questionnaire and MD (r = 0.79), Pattern Standard Deviation (PSD) (r = -0.68) and CPSD (r = -0.61).

CONCLUSION

Viswanathan et al's questionnaire was more useful than MOS SF-36, both for the score and for the velocity to use. Furthermore Viswanathan et al's questionnaire was more significantly correlated to visual field MD.

Correlation of visual field with quality-of-life measures at diagnosis in the Collaborative Initial Glaucoma Treatment Study (CIGTS)

PURPOSE

To examine the relationship between various clinical measures of visual field and patient-reported measures of symptoms and health status in a large cohort of patients with glaucoma at the time of diagnosis.

PATIENTS AND METHODS

The 607 patients in the Collaborative Initial Glaucoma Treatment Study received standardized examinations of visual field at enrollment. In addition, they completed a telephone-administered, health-related quality-of-life questionnaire, which included the Visual Activities Questionnaire (VAQ) and a symptom and health problem checklist.

RESULTS

The Visual Activities Questionnaire total and subscale scores, particularly the peripheral vision subscale, correlated weakly but significantly with global visual field scores. Symptoms attributed to glaucoma also correlated weakly but significantly to visual field scores. Correlations with other visual field measures, including only central and pericentral test locations in the scores, did not strengthen the association, and simulating binocular visual field scores produced only slightly stronger correlations.

CONCLUSIONS

At diagnosis, most patients were relatively free of glaucoma-related impairments. Various visual field measures derived from clinical visual field test data were only modestly associated with patients' perceptions of health-related quality of life. As the Collaborative Initial Glaucoma Treatment Study population is followed up longitudinally, it will be important to see whether these pertinent associations become stronger.

Design of the low vision quality-of-life questionnaire (LVQOL) and measuring the outcome of low-vision rehabilitation

PURPOSE

To design and validate a vision-specific quality-of-life assessment tool to be used in a clinical setting to evaluate low-vision rehabilitation strategy and management.

METHODS

Previous vision-related questionnaires were assessed by low-vision rehabilitation professionals and patients for relevance and coverage. The 74 items selected were pretested to ensure correct interpretation. One hundred and fifty patients with low vision completed the chosen questions on four occasions to allow the selection of the most appropriate items. The vision-specific quality of life of patients with low vision was compared with that of 70 age-matched and gender-matched patients with normal vision and before and after low-vision rehabilitation in 278 patients.

RESULTS

Items that were unreliable, internally inconsistent, redundant, or not relevant were excluded, resulting in the 25-item Low Vision Quality-of-Life Questionnaire (LVQOL). Completion of the LVQOL results in a summed score between 0 (a low quality of life) and 125 (a high quality of life). The LVQOL has a high internal consistency (alpha = 0.88) and good reliability (0.72). The average LVQOL score for a population with low vision (60.9 +/- 25.1) was significantly lower than the average score of those with normal vision (100.3 +/- 20.8). Rehabilitation improved the LVQOL score of those with low vision by an average of 6.8 +/- 15.6 (17%).

CONCLUSIONS

The LVQOL was shown to be an internally consistent, reliable, and fast method for measuring the vision-specific quality of life of the visually impaired in a clinical setting. It is able to quantify the quality of life of those with low vision and is useful in determining the effects of low-vision rehabilitation.

Patients' perception of visual impairment in glaucoma: a pilot study

BACKGROUND/AIMS

There is a paucity of useful information on the level of visual disability suffered by glaucoma patients. The aims of this study were to determine and rank the frequency of self reported visual disability in daily tasks performed by glaucoma patients; to examine the interrelation between disabilities using factor analysis; to study the relation between perceived visual difficulty and a measure of the severity of visual field loss; to develop a glaucoma specific subgroup of questions; and examine the validity and reliability of this subgroup of questions.

METHODS

63 glaucoma patients completed a questionnaire containing 62 questions covering 10 broad aspects of daily life activities using a five point answer scale. Patients were classified into three groups as having mild, moderate, and severe field loss on the basis of the perimetric results. The relation between a measure of the severity of visual field loss and subjective visual disability in the three groups was examined.

RESULTS

Using factor analysis, the most frequently reported problems were grouped into the following four categories: outdoor mobility, glare and lighting conditions and activities demanding functional peripheral vision, household tasks, and personal care. These four factors accounted for 72% of the variability in the patients' questionnaire responses. With increasing severity of binocular visual field loss there was an increase in the number of self reported visual problems. A loss of confidence in performing some routine daily tasks tended to precede self reported specific visual disabilities. The factor "glare and lighting and activities demanding functional peripheral vision" was found to have a significant relation with a measure of visual field loss and was used to create a glaucoma specific subset of questions. Cronbach's alpha showed a high degree of reliability and internal consistency (alpha =0.96) in this glaucoma specific subset of questions. Furthermore, the validity of this new subset of questions was shown to be significant (r=0.037, p<0.05) for the correlation between a measure of the severity of binocular visual field loss and the mean score of the variables used in the glaucoma specific subgroup of questions.

CONCLUSIONS

Outcome measures and quality of life issues need to be addressed in glaucoma. This pilot study identified common problems encountered by patients which at the present time are not assessed in routine glaucoma care. It also identified a subgroup of questions that seems to be specific for glaucoma. Further research is required if a significant impact on the quality of life of glaucoma patients is to be achieved.

Associations of performance-based and self-reported measures of visual function. The Beaver Dam Eye Study

OBJECTIVE

To describe and compare performance-based and self-reported measures of visual function and to evaluate how each varied with age and how the performance-based measures were associated with the responses to self-reported questions about visual function.

DESIGN

Population-based epidemiologic study.

PARTICIPANTS

Adults participating in the first follow-up of the Beaver Dam Eye Study (n = 3,722).

MAIN OUTCOME MEASURES

Performance-based measures of vision including current binocular, best-corrected and near visual acuities, sensitivity to light as measured by an automated perimeter, contrast sensitivity, and self-reported measures from a standardized interview.

RESULTS

All performance-based and self-reported visual functions decreased with increasing age (p < 0.0001 for each). On average, women did more poorly than men on all the performance-based measures (p < 0.0001 for each), and on some of the self-reported measures. For both genders, correlations among the performance-based measures ranged from 0.38 to 0.67. In general, individuals reporting good visual function or little difficulty with visual tasks scored better on performance-based measures compared to individuals whose questionnaire responses reflected limited visual function. Overall, about 39% of drivers reported that their vision caused them to limit their night driving. Correlations of performance-based with self-reported measures of visual function were greater for best-corrected, binocular and near visual acuity compared to correlations of visual sensitivity to light and contrast sensitivity. There were 1,285 persons whose best-corrected acuity was better than their current binocular acuity and there were 97 people with visual impairment considering only current binocular acuity whose vision improved to better than 20/40 after refraction.

CONCLUSIONS

Performance-based and self-reported measures of visual function were consistently and inversely related to age. Performance-based measures were, in general, more highly correlated between themselves than were self-reported measures. Self-reported visual functions were significantly positively correlated with all performance-based measures, but correlations were moderate. While high contrast measures are usually used in clinical settings and in many studies, the data suggest that in assessing function it is appropriate to measure several different aspects of vision, both performance-based and self-assessed. Our data give some indication of the impact these visual functions have on daily life as reflected by night driving and on near and distant visual acuity. New refractive corrections would likely improve the visual acuity in many older adults.

Simulating binocular visual field status in glaucoma

AIMS

To simulate the central binocular visual field using results from merged left and right monocular Humphrey fields. To assess the agreement between the simulation and the binocular Humphrey Esterman visual field test (EVFT).

METHOD

59 consecutive patients with bilateral glaucoma each recorded Humphrey 24-2 fields for both eyes and binocular EVFT on the same visit. EVFT results were used to identify patients exhibiting at least one defect (< 10 dB) within the central 20 degrees of the binocular field. This criterion is relevant to a patient's legal fitness to drive in the UK. Individual sensitivity values from monocular fields are merged to generate a simulated central binocular field. Results are displayed as a grey scale and as symbols representing defects at the < 10 dB level. Agreement between patients failing the criterion using the simulation and the EVFT was evaluated.

RESULTS

Substantial agreement was observed between the methods in classifying patients with at least one defect (< 10 dB) within the central binocular field (kappa 0.81; SE 0.09). Patients failing this criterion using the EVFT results were identified by the binocular simulation with high levels of sensitivity (100%) and specificity (86%).

CONCLUSIONS

Excellent agreement exists between the simulated binocular results and EVFT in classifying glaucomatous patients with central binocular defects. A rapid estimate of a patient's central binocular field and visual functional capacity can be ascertained without extra perimetric examination.

What effect does laser photocoagulation have on driving visual fields in diabetics?

Although laser panretinal photocoagulation (PRP) for proliferative diabetic retinopathy is known to cause peripheral field constriction, the risks of failing the UK driving field test following treatment are currently unclear as the small number of previous studies have conflicting results. Following PRP using only argon laser with a 500 microns spot size, both uniocular and binocular Esterman visual fields from 60 diabetic patients were assessed by the Chairman of the Visual Standards Sub-Committee of the Royal College of Ophthalmologists. Forty-two per cent of uniocular fields from treated eyes failed. Twelve per cent of binocular fields from those having bilateral PRP failed. Type II diabetes was associated with a significant increase in the risk of failure. Although there is a high risk of failure in any given treated eye, 88% of diabetics will pass a binocular field test, even if both eyes are treated.

Vitreoretinal surgery outcomes. Impact on bilateral visual function

PURPOSE

The authors evaluated the impact of vitreoretinal surgery for epiretinal membrane (ERM), rhegmatogenous retinal detachment (RRD), and complex retinal detachment (CRD) on bilateral visual function.

METHODS

Anatomic and visual acuity outcomes were reviewed by the authors for all patients who underwent surgery for ERM, RRD, or CRD during a 2-year period. Several outcome measures of bilateral visual function were applied to quantitate the impact of surgery on bilateral visual function. Data were also analyzed by subdividing patients into two cohorts based on whether vision in the fellow eye was normal (visual acuity > or = 20/40) or abnormal (visual acuity < or = 20/50) at baseline.

RESULTS

Anatomic and visual acuity outcomes of 187 study eyes were similar to previous studies. Postoperatively, the study eye was the eye with better vision in 30.9%, 26.8%, and 16.7% of patients with ERM, RRD, and CRD, respectively. The mean bilateral visual impairment according to American Medical Association Guidelines for Disability decreased postoperatively by 8.7% points, 6.8% points, and 3.6% points, respectively, and decreased most when vision in the fellow eye was abnormal. A higher bilateral visual system functional level resulted postoperatively in 10.7% of all patients, including 28.6% of patients with abnormal vision in the fellow eye (by definition, the visual system functional level of patients with normal vision in the fellow eye could not be improved).

CONCLUSIONS

Surgery was associated with a reduction in bilateral visual disability among patients with ERM, RRD, and CRD, and 28.6% of patients with abnormal vision in the fellow eye achieved a higher bilateral visual functional level.

How much blame can be placed on laser photocoagulation for failure to attain driving standards?

One hundred consecutive patients who underwent bilateral pan-retinal photocoagulation (PRP) for proliferative diabetic retinopathy were assessed in accordance with the UK Driver and Vehicle Licensing Agency (DVLA) guidelines. Visual acuity was documented, and visual fields were assessed using the Esterman test. Among the 30% of patients who failed to reach the visual standards required for a driving licence, three groups were identified: those who failed to attain either the required binocular visual acuity (n = 4), or visual fields (n = 9), or both (n = 17). Previous studies reveal a large variation in DVLA field test failure following PRP treatment for proliferative diabetic retinopathy. Our results show a 19% failure rate solely attributable to treatment, which is at the lower end of previously reported studies (20-80%). The reasons for this discrepancy are discussed. We conclude that modern treatment procedures for proliferative diabetic retinopathy may be undertaken with the knowledge that in the majority of cases a patient's driving licence is unlikely to be revoked.