Change in quality of life after rehabilitation: prognostic factors for visually impaired adults

Retinitis Pigmentosa: Current Clinical Management and Emerging Therapies

Retinitis pigmentosa (RP) comprises a group of inherited retinal dystrophies characterized by the degeneration of rod photoreceptors, followed by the degeneration of cone photoreceptors. As a result of photoreceptor degeneration, affected individuals experience gradual loss of visual function, with primary symptoms of progressive nyctalopia, constricted visual fields and, ultimately, central vision loss. The onset, severity and clinical course of RP shows great variability and unpredictability, with most patients already experiencing some degree of visual disability in childhood. While RP is currently untreatable for the majority of patients, significant efforts have been made in the development of genetic therapies, which offer new hope for treatment for patients affected by inherited retinal dystrophies. In this exciting era of emerging gene therapies, it remains imperative to continue supporting patients with RP using all available options to manage their condition. Patients with RP experience a wide variety of physical, mental and social-emotional difficulties during their lifetime, of which some require timely intervention. This review aims to familiarize readers with clinical management options that are currently available for patients with RP.

Artificial vision: the effectiveness of the OrCam in patients with advanced inherited retinal dystrophies

Purpose

To investigate the impact of the OrCam MyEye 2.0 (OrCam) on the quality of life and rehabilitation needs in patients with advanced retinitis pigmentosa (RP) or cone‐rod dystrophies (CRD). The OrCam is a wearable low‐vision aid that converts visual information to auditive feedback (e.g. text‐to‐speech, barcode and facial recognition).

Methods

Patients with a clinical diagnosis of RP (n = 9, 45%) or CRD (n = 11; 55%), and a best‐corrected visual acuity of ≤20/400 Snellen were invited to participate in this study. Questionnaires were administered at baseline and after 5.2 (standard deviation ± 1.5) weeks, which included the Dutch version of the National Eye Institute Visual Functioning Questionnaire (NEI‐VFQ), the Participation and Activity Inventory (PAI) and the OrCam Function Questionnaire (OFQ).

Results

Following OrCam testing, significant improvements were observed in the ‘near activities’ subscale of the NEI‐VFQ (p < 0.001); the ‘visual functioning’ subscale of the re‐engineered NEI‐VFQ (p = 0.001); the ‘reading’ rehabilitation goal of the PAI (p = 0.005) and the overall score of the OFQ (p < 0.001). The observed changes in questionnaire scores did not differ between phenotypes. Advantages and limitations of the OrCam were reported by patients. Three patients (15%) continued rehabilitation with the OrCam after completion of this study.

Conclusions

The OrCam mainly improves reading domains in patients with advanced stages of RP or CRD. Further improvements in the OrCam are needed to address current limitations, which may enhance its utility for patients with RP or CRD.

Reliability and validity of the Canadian-French ecological adaptation of the weighted version of the Melbourne low-vision ADL Index

Background: The Mesure de l'impact de la déficience visuelle dans les activités quotidiennes (MIDVAQ) is the Canadian-French adaptation of the Melbourne Low-Vision ADL Index. It measures performance, personal importance and handicap situation in 16 instrumental activities requiring near vision (standardized material, part A) and in 9 self-care and domestic activities (self-report questionnaire, part B). This study aimed at measuring the MIDVAQ reliability and its relationship with measures of visual functions and functional vision.Methods: The MIDVAQ was administered twice to 100 visually impaired participants, at home, with their personal visual and non-visual aid. A second rater was present at T1. Two different versions of part A were used alternately at T1 and T2.Results: The total Handicap scale demonstrates good internal reliability (Cronbach's alpha coefficient = 0.82) and very high inter-rater and test-retest reliability (ICCs = 1.00 and 0.86). Part A alternative versions are highly comparable. Vision function measures are significantly correlated with total Handicap score, for which 48% of the variance is explained by functional vision estimates, age, and education.Conclusions: The MIDVAQ is highly valid and reliable. It can be useful to measure the functional impact of the visual impairment, its progression, and the outcomes of low vision rehabilitation services.Implications for rehabilitationEven if administered at home in an ecological way, this measure of the impact of the visual impairment in daily activities is very reliable.Given its good metric properties, this tool can be confidently used to assess the functional impact of visual impairment, outcomes of the low vision rehabilitation services, etc.This measurement tool provides complementary information to those obtained from clinical measures of visual functions, by reflecting the interaction between the functional abilities with the requirements of the environment.

A Nurse's Perspective on Visual Rehabilitation of Outpatients With Low Vision in China

PURPOSE

The purposes of the study were to analyze patient use and satisfaction with low vision aids (LVAs) at the Wenzhou Medical University Low Vision and Rehabilitation Center and to assess the promotion of visual rehabilitation services as a new responsibility for nurses in China.

METHODS

Records of 178 patients with low vision (LV) from the Low Vision and Rehabilitation Center examined between October 2015 and October 2016 included basic patient information (e.g., age, diagnosis, visual acuity, educational level) and use of LVAs (patients' own aids, daily duration of LVA use, or refusal to use aids).

RESULTS

Sixty percent owned LVAs. Of these, 66% were obtained from a hospital, 26% were obtained from commercial stores, and others were obtained from government or gifts. Patients reported that use of LVAs was reduced because of visual fatigue (39%), inconvenience (22%), and lack of benefit (12%). Reasons for the 40% who had never used visual rehabilitation were nonreferral by doctors (76%), refusal because of inconvenience, discomfort and cosmetics (20%), or a preference for other treatments (4%).

CONCLUSIONS

Greater awareness of LV rehabilitation by nurses, ophthalmologists, patients, and the public is necessary. Additional government support for LV rehabilitation is also required.

Effect of Different Visual Impairment Levels on the Quality of Life in Glaucoma Patients

The aim of this study was to assess the effect of different visual impairment levels on difference in the subjective quality of life estimation. We included 150 patients with glaucoma whose best-corrected visual acuity in the better-seeing eye was 0.5 and less. All of them were in advanced stage of the disease, with visual field defect worse than 12 dB in mean defect, when measured with the Octopus Visual Field Analyzer. In order to assess the quality of life, we used the Impact of Vision Impairment questionnaire. Additionally, we used General Information Questionnaire, which was developed for the purpose of this study. The information obtained from the questionnaires was analyzed using the Robust Discriminant Analysis program. Difference analysis was performed for each of the three areas of the questionnaire (reading and accessing information, mobility and inde-pendence, and emotional well-being). Results of this study confirmed the difference between the groups of patients with different levels of visual impairment, varying from total visual loss up to vis-ual acuity 0.5 on the better-seeing eye in the effects of visual impairment on the quality of life. All levels of visual impairment had the largest effect in the area of reading and accessing information, slightly less in the area of mobility and independence, and the least effect was in the area of emotional well-being. Based on the results, it is concluded that all levels of visual impairment have negative effect on the quality of life in glaucoma patients.

Low Vision Rehabilitation for Adult African Americans in Two Settings

PURPOSE

The Vision Rehabilitation for African Americans with Central Vision Impairment (VISRAC) study is a demonstration project evaluating how modifications in vision rehabilitation can improve the use of functional vision.

METHODS

Fifty-five African Americans 40 years of age and older with central vision impairment were randomly assigned to receive either clinic-based (CB) or home-based (HB) low vision rehabilitation services. Forty-eight subjects completed the study. The primary outcome was the change in functional vision in activities of daily living, as assessed with the Veteran's Administration Low-Vision Visual Function Questionnaire (VFQ-48). This included scores for overall visual ability and visual ability domains (reading, mobility, visual information processing, and visual motor skills). Each score was normalized into logit estimates by Rasch analysis. Linear regression models were used to compare the difference in the total score and each domain score between the two intervention groups. The significance level for each comparison was set at 0.05.

RESULTS

Both CB and HB groups showed significant improvement in overall visual ability at the final visit compared with baseline. The CB group showed greater improvement than the HB group (mean of 1.28 vs. 0.87 logits change), though the group difference is not significant (p = 0.057). The CB group visual motor skills score showed significant improvement over the HB group score (mean of 3.30 vs. 1.34 logits change, p = 0.044). The differences in improvement of the reading and visual information processing scores were not significant (p = 0.054 and p = 0.509) between groups. Neither group had significant improvement in the mobility score, which was not part of the rehabilitation program.

CONCLUSIONS

Vision rehabilitation is effective for this study population regardless of location. Possible reasons why the CB group performed better than the HB group include a number of psychosocial factors as well as the more standardized distraction-free work environment within the clinic setting.

Low vision rehabilitation plans comparing two intake methods

PURPOSE

This qualitative study investigates possible differences in identified rehabilitation needs indicated by the usual intake procedures at a Multidisciplinary Rehabilitation Center (MRC) for visually impaired persons compared with those indicated by the use of a structured Dutch version [based on the International Classification of the Disability, Functioning and Health (ICF)] of the Activity Inventory (D-AI).

METHODS

Twenty patients who enrolled at the MRC received a D-AI assessment by telephone, in addition to the usual intake. All patients received usual care, based on rehabilitation needs identified by the usual intake procedure at the MRC. Rehabilitation needs identified at the MRC were obtained from patient files retrospectively and were compared with rehabilitation needs identified by the D-AI.

RESULTS

The mean number of rehabilitation needs reported in the patient files was 6.9 (± 5.1) vs. 24.0 (± 11.2) using the D-AI. Only 22.6% (± 14.3) of the rehabilitation needs identified by the D-AI were present in the patient files; 79.3% (± 28.2) of the rehabilitation needs reported in the patient files were identified by the D-AI. Overall agreement corrected for chance between both intake methods revealed a fair Cohen kappa of 0.27.

CONCLUSIONS

At the MRC, more needs were revealed using the D-AI compared with the usual intake procedure. The systematic character of the D-AI prevents important topics being overlooked. In the usual intake, it was not clear whether needs were investigated from the patient's perspective. This may hamper (medical) communication and shared decision making about the rehabilitation program that needs to be followed. Moreover, using the unstructured information from the patient files makes it difficult to evaluate rehabilitation outcomes. With the D-AI, although an extensive overview of rehabilitation needs is produced, it remains difficult to focus on the most relevant needs. However, after assessment with the D-AI, all aspects of the ICF, Disability, and Health scheme can be discussed in a process of shared decision making, which leads to the final determination of rehabilitation goals.

A Dutch ICF version of the Activity Inventory: results from focus groups with visually impaired persons and experts

PURPOSE

To develop a valid and reliable instrument to systematically investigate visual rehabilitation needs of visually impaired older adults, which is compatible with the "International Classification of Functioning, Disability and Health" (ICF) structure: a new Dutch ICF version of the Activity Inventory (D-AI).

METHODS

The original AI was translated, adjusted and expanded. After studying literature and investigating patient records, focus group discussions were conducted until the input was just confirmatory. Six (n = 41) and seven (n = 50) discussions with patients and professionals respectively contributed to the first draft of the D-AI, which was further improved by professionals.

RESULTS

The D-AI now consists of 10 domains, 68 goals and 813 tasks. Goals are organized into the "Activities and Participation" domains of the ICF. The original routing was maintained; only tasks organized under important (0 [not important] to 3 [very important]) and difficult (0 [not difficult] to 4 [impossible]) goals were assessed.

CONCLUSION

Rehabilitation needs can be organized in the "Activities and Participation" domains of the ICF. The D-AI offers a way of systematically assessing and measuring functional limitations and disabilities, and provides detailed information about activities that are needed to perform a certain goal. Focus group discussions with Dutch patients and experts revealed additional items that will probably be relevant for other populations. Involving patients in the first step of the developing process is important to provide face and content validity. The D-AI can prioritize rehabilitation goals by multiplying importance and difficulty scores, which is helpful in formulating a rehabilitation plan.

Feasibility of the Dutch ICF Activity Inventory: a pilot study

Background

Demographic ageing will lead to increasing pressure on visual rehabilitation services, which need to be efficiently organised in the near future. The Dutch ICF Activity Inventory (D-AI) was developed to assess the rehabilitation needs of visually impaired persons. This pilot study tests the feasibility of the D-AI using a computer-assisted telephone interview.

Methods

In addition to the regular intake, the first version of the D-AI was assessed in 20 patients. Subsequently, patients and intake assessors were asked to fill in an evaluation form. Based on these evaluations, a new version of the D-AI was developed.

Results

Mean administration time of the D-AI was 88.8 (± 41.0) minutes. Overall, patients and assessors were positive about the D-AI assessment. However, professionals and 60% of the patients found the administration time to be too long. All included items were considered relevant and only minor adjustments were recommended.

Conclusion

The systematic character of the revised D-AI will prevent topics from being overlooked and indicate which needs have the highest priority from a patient-centred perspective. Moreover, ongoing assessment of the D-AI will enhance evaluation of the rehabilitation process. To decrease administration time, in the revised D-AI only the top priority goals will be fully assessed. Using the D-AI, a rehabilitation plan based on individual needs can be developed for each patient. Moreover, it enables better evaluation of the effects of rehabilitation. A larger validation study is planned.

The impact of reduced distance and near vision on the quality of life of adults in Timor-Leste

PURPOSE

To determine the independent, relative, and combined impact of reduced distance and near vision on the vision-specific quality of life (VS QOL) of adults in Timor-Leste.

DESIGN

A population-based cross-sectional eye health survey was conducted in urban and rural areas in Timor-Leste.

PARTICIPANTS

Participants were 40 years or older. Those with better eye presenting distance vision worse than 6/18, and every third participant with 6/18 or better vision, completed the VS QOL questionnaire: in total 704 of the 1414 participants.

METHODS

Distance and near visual acuities were measured and eye health was assessed. The VS QOL questionnaire administered by interview was analyzed using Rasch analysis, univariate analysis, and linear regression to determine associations between VS QOL, demographic factors, and levels of visual impairment.

MAIN OUTCOME MEASURES

The Timor-Leste VS QOL questionnaire results.

RESULTS

Rasch analysis confirmed that for participants both with and without visual impairment, the Timor-Leste VS QOL questionnaire provided a valid and reliable measure, was unidimensional, and had appropriate response categories. There was a consistent pattern of deterioration in VS QOL as vision worsened: for each category of distance- and near-vision impairment, there was an independent and significant change in Timor-Leste VS QOL scores between no visual impairment and either mild, moderate, or severe impairment (P < 0.05). Combined distance- and near-vision impairment was associated with a greater impact on VS QOL than categories separately, the impact of severe distance- and near-vision impairment being the greatest and clinically significant: -3.05 (95% confidence interval [CI], -3.60 to -2.49; P<0.05; and 95% CI, <-1.0). Distance vision (37.2%) contributed relatively more than near vision (4.7%) to the total variance in VS QOL (41.9%). Older people, those not married, not literate, and rural dwellers had significantly worse Timor-Leste VS QOL scores (P < 0.05).

CONCLUSIONS

This study provides evidence of independent dose-response relationships between distance- and near-vision impairment and poorer VS QOL. Distance-vision impairment had a relatively larger impact on VS QOL than near-vision impairment. Combined distance- and near-vision impairment was associated with a greater impact on VS QOL compared with the independent impact of distance- or near-vision impairment at similar levels.