Quality of life and visual impairment from cataract in Satkhira district, Bangladesh

Travel time to cataract surgical services in Kenya, Malawi and Rwanda: demonstrating a standardised indicator of physical access to cataract surgery

BACKGROUND

Travel time can be used to assess health services accessibility by reflecting the proximity of services to the people they serve. We aimed to demonstrate an indicator of physical access to cataract surgery and identify subnational locations where people were more at risk of not accessing cataract surgery.

METHODS

We used an open-access inventory of public health facilities plus key informants in Kenya, Malawi and Rwanda to compile a geocoded inventory of cataract facilities. For each country, gridded estimates of the population aged ≥ 50 years and a travel-time friction surface were combined and a least-cost-path algorithm applied to estimate the shortest travel time between each grid and the nearest cataract facility. We categorised continuous travel time by 1-, 2- and 3 h thresholds and calculated the proportion of the population in each category.

RESULTS

At the national level, the proportion of the population aged ≥ 50 years within 2 h travel time to permanent cataract surgical services was 97.2% in Rwanda (n = 10 facilities), 93.5% in Kenya (n = 74 facilities) and 92.0% in Malawi (n = 6 facilities); this reduced to 77.5%, 84.1% and 52.4% within 1 h, respectively. The least densely populated subnational regions had the poorest access to cataract facilities in Malawi (0.0%) and Kenya (1.9%).

CONCLUSION

We demonstrated an indicator of access that reflects the distribution of the population at risk of age-related cataract and identifies regions that could benefit from more accessible services. This indicator provides additional demand-side context for eye health planning and supports WHO's goal of advancing integrated people-centred eye care.

Impact of major age-related eye disorders on health-related quality of life assessed by EQ-5D: a systematic review and meta-analysis

PURPOSE

This study is to quantitatively estimate the health-related quality of life (HRQOL) impact of major age-related eye diseases (AREDs) including cataract, glaucoma, age-related macular degeneration (AMD), and diabetic retinopathy (DR) assessed by the EuroQoL Five-Dimensional Questionnaire (EQ-5D).

METHODS

PubMed, Embase, Cochrane Library, and CINAHL were searched until October 20, 2022. Studies were included if they reported the EQ-5D health utility score (HUS) or visual analogue scale (VAS) score of both AREDs patients and healthy controls. The mean difference (MD) in HUS or VAS score between cases and controls and its 95% confidence interval (95%CI) were pooled using the random-effects model. We also performed sensitivity analysis using the leaving-one-out method and subgroup analyses by sample size and race. The prevalence in reporting any problems in the five EQ-5D dimensions was summarized and compared between cases and controls using the Chi-square test.

RESULTS

Fifteen articles involving 30,491 participants were included in this review. Pooled estimates indicated reduced HUS in AMD patients (MD = - 0.04, 95%CI - 0.07, - 0.01; P = 0.009), DR patients (MD = - 0.03, 95%CI - 0.05, - 0.01; P = 0.01), and glaucoma patients (MD = - 0.06, 95%CI - 0.10, - 0.01; P = 0.01), compared with the controls. Significantly lower EQ-5D VAS score was also observed in cataract patients (MD = - 11.33, 95%CI - 13.47, - 9.18; P < 0.001) and DR patients (MD = - 6.41, 95%CI - 10.64, - 2.18; P = 0.003). AREDs patients reported usual activities and anxiety/depression problems more frequently than the control group.

CONCLUSIONS

Our findings confirmed the HRQOL impairment caused by major AREDs including AMD, cataract, DR, and glaucoma. High-quality studies with large sample sizes are warranted to further verify our results.

Association of Visual Health With Depressive Symptoms and Brain Imaging Phenotypes Among Middle-Aged and Older Adults

IMPORTANCE

Vision loss and depression are common conditions with major health implications. However, mechanisms of the association of visual health (across the full acuity spectrum) with depression remain unclear.

OBJECTIVE

To characterize the association between visual health and depression and investigate the association between depression and brain microstructure and macrostructure in subgroups divided by visual acuity.

DESIGN, SETTING, AND PARTICIPANTS

In the UK Biobank Study cohort, 114 583 volunteers were included at baseline from March to June 2006 to July 2010. Habitual distance visual acuity was examined using the logarithm of the minimum angle of resolution (LogMAR) characters. Depression was identified based on Patient Health Questionnaire (PHQ) or through an interview-based psychiatric diagnosis. Subgroup participants completed multimodal magnetic resonance imaging (MRI) of the brain and PHQ evaluation during the imaging visit after 2014. Data were analyzed from May 5 to August 9, 2022.

MAIN OUTCOMES AND MEASURES

Depression, depressive symptoms, and imaging-derived phenotypes from T1-weighted and diffusion MRI.

RESULTS

Of the 114 583 participants from the UK Biobank Study, 62 401 (54.5%) were women, and the mean (SD) age was 56.8 (8.1) years (range, 39-72 years). A 1-line worse visual acuity (0.1 LogMAR increase) was associated with 5% higher odds of depression (odds ratio, 1.05 [95% CI, 1.04-1.07]) after adjustment for age, sex, race and ethnicity, Townsend index, educational qualifications, smoking, alcohol consumption, obesity, physical activity, history of hypertension, diabetes, hyperlipidemia, and family history of depression. Of the 7844 participants eligible for MRI analysis, there were linear associations between PHQ score and the left volume of gray matter in supracalcarine cortex (coefficient, 7.61 [95% CI, 3.90-11.31]) and mean isotropic volume fraction (ISOVF) in the right fornix (cres) and/or stria terminalis (coefficient, 0.003 [95% CI, 0.001-0.004]) after correction for multiple comparison. In addition, their association could be moderated by visual acuity, whereby increased PHQ score was associated with higher ISOVF levels only among those with poorer visual acuity (P = .02 for interaction).

CONCLUSIONS AND RELEVANCE

This study suggests an association between visual health and depression and that the diffusion characteristic of ISOVF in the fornix (cres) and/or stria terminalis is associated with depressive symptoms in participants with poorer visual acuity.

Vision impairment and self-reported anxiety and depression in older adults in Nigeria: evidence from a cross-sectional survey in Kogi State

BACKGROUND

More than 2 billion people are thought to be living with some form of vision impairment worldwide. Yet relatively little is known about the wider impacts of vision loss on individual health and well-being, particularly in low- and middle-income countries (LMICs). This study estimated the associations between all-cause vision impairment and self-reported symptoms of anxiety and depression among older adults in Kogi State, Nigeria.

METHODS

Individual eyes were examined according to the standard Rapid Assessment of Avoidable Blindness methodology, and anxiety and depression were assessed using the Washington Group Short Set on Functioning-Enhanced. The associations were estimated using multivariable logistic regression models, adding two- and three-way interaction terms to test whether these differed for gender subgroups and with age.

RESULTS

Overall, symptoms of either anxiety or depression, or both, were worse among people with severe visual impairment or blindness compared with those with no impairment (OR=2.72, 95% CI 1.86 to 3.99). Higher levels of anxiety and/or depression were observed among men with severe visual impairment and blindness compared with women, and this gender gap appeared to widen as people got older.

CONCLUSIONS

These findings suggest a substantial mental health burden among people with vision impairment in LMICs, particularly older men, underscoring the importance of targeted policies and programmes addressing the preventable causes of vision impairment and blindness.

Causes and Five-Year Proportion of New Irreversible Visual Impairment in Jinshan District, Shanghai, from 2009-2018

Purpose

To describe the age distribution and main causes of new registered irreversible visual impairment (VI) and to compare the five-year proportion of VI in Jinshan district, Shanghai, from 2009 to 2018.

Methods

The new irreversible VI data were collected in the registry system from the Disabled Persons' Federation in Jinshan district from January 1, 2009, to December 31, 2018. Age, gender, and causes of VI were included, and the 5-year proportion of VI was calculated.

Results

The peak occurrence of blindness occurred in the 50–59 yrs group in 2009–2013 and in the ≥70 yrs group in 2014–2018. The peak occurrence of low vision occurred in the 40–49 yrs group in 2009–2013 and in the 50–59 yrs group in 2014–2018. Myopic macular degeneration (MMD, 15.5%), diabetic retinopathy (DR, 14.3%), and other optic nerve atrophy (ONA, 14.3%) were the three leading causes of blindness in 2009-2013, whereas MMD (21.3%), age-related macular degeneration (AMD, 19.6%), ONA (14.9%) were the three leading causes of blindness in 2014–2018. MMD (39.2%), DR (9.6%), ONA (8.8%) were the three leading causes of low vision in 2009–2013, whereas MMD (38.7%), AMD (23.3%), ONA (7.4%) were the three leading causes of low vision in 2014–2018. The proportions of blindness and low vision caused by AMD were higher in 2014–2018 than those in 2009–2013 (P=0.034 and P < 0.001, respectively).

Conclusion

The present study demonstrated an increasing trend in the number of irreversibly visually impaired individuals from 2009 to 2018. More attention should be paid to people with high myopia and old age.

Burden of visual impairment in mainland China: the Handan Eye Study and Beijing Eye Study

PURPOSE

To determine the impact of visual impairment (VI) on health-related quality of life (HRQoL) and to compare the health burden of VI in different areas in mainland China.

METHODS

A cohort of 6830 people from rural villages and a cohort of 3251 people from an urban city were included to receive comprehensive ophthalmologic examinations and complete the European Quality of Life-5 Dimensions 3 Levels (EQ-5D-3L) questionnaire. For urban and rural populations, a unified VI grouping standard was adopted: the eyes were classified into normal group, mild-moderate group, and severe group according to WHO standards, and then divided into 6 groups considering both eyes. We estimated the effects of VI on the EQ-5D index score using linear regression models and the association between VI and self-reported EQ-5D health problems using logistic regression models. Associations were assessed by the Spearman correlation coefficient.

RESULTS

The prevalence of VI and the index scores of EQ-5D-3L for each subgroup of VI were higher for the rural cohort. In these two cohorts, the severity of VI in rural population (Spearman r = 0.205; p < 0.0001) and urban population (Spearman r = 0.164; p < 0.0001) is correlated with the EQ-5D index score. In the rural cohort, the difference in index scores with bilateral severe VI compared to those without VI, after adjusting for covariates, was - 0.053 for the rural cohort and - 0.084 for the urban cohort, respectively. In the rural cohort, the odds ratio for bilateral severe VI was 4.39 for mobility, 6.33 for self-care, and 5.88 for usual activities. The incidence of anxiety or depression and pain or discomfort in the urban cohort was greater; the OR for bilateral severe VI in the urban cohort was 4.75.

CONCLUSIONS

VI has a negative impact on HRQoL in the rural and urban areas of China, especially in urban population. It is also more likely to cause anxiety or depression among the urban cohort, which deserves special attention.

Topical chlorhexidine 0.2% versus topical natamycin 5% for fungal keratitis in Nepal: rationale and design of a randomised controlled non-inferiority trial

INTRODUCTION

Fungal infections of the cornea, fungal keratitis (FK), are challenging to treat. Current topical antifungals are not always effective and are often unavailable, particularly in low-income and middle-income countries where most cases occur. Topical natamycin 5% is usually first-line treatment, however, even when treated intensively, infections may progress to perforation of the eye in around a quarter of cases. Alternative antifungal medications are needed to treat this blinding disease.Chlorhexidine is an antiseptic agent with antibacterial and antifungal properties. Previous pilot studies suggest that topical chlorhexidine 0.2% compares favourably with topical natamycin. Full-scale randomised controlled trials (RCTs) of topical chlorhexidine 0.2% are warranted to answer this question definitively.

METHODS AND ANALYSIS

We will test the hypothesis that topical chlorhexidine 0.2% is non-inferior to topical natamycin 5% in a two-arm, single-masked RCT. Participants are adults with FK presenting to a tertiary ophthalmic hospital in Nepal. Baseline assessment includes history, examination, photography, in vivo confocal microscopy and cornea scrapes for microbiology. Participants will be randomised to alternative topical antifungal treatments (topical chlorhexidine 0.2% and topical natamycin 5%; 1:1 ratio, 2-6 random block size). Patients are reviewed at day 2, day 7 (with reculture), day 14, day 21, month 2 and month 3. The primary outcome is the best spectacle corrected visual acuity (BSCVA) at 3 months. Primary analysis (intention to treat) will be by linear regression, with treatment arm and baseline BSCVA prespecified covariates. Secondary outcomes include epithelial healing time, scar/infiltrate size, ulcer depth, hypopyon size, perforation and/or therapeutic penetrating keratoplasty (corneal transplant), positive reculture rate (day 7) and quality of life (EuroQol-5 dimensions, WHO/PBD-VF20, WHOQOL-BREF).

ETHICS AND DISSEMINATION

The Nepal Health Research Council, the Nepal Department of Drug Administration and the London School of Hygiene and Tropical Medicine ethics committee have approved the trial. The results will be presented at local and international meetings and submitted to peer-reviewed journals for publication.

TRIAL REGISTRATION NUMBER

ISRCTN14332621; pre-results.

Gender differences in quality of life among community-dwelling older adults in low- and middle-income countries: results from the Study on global AGEing and adult health (SAGE)

Background

Quality of life (QoL) is an important component of individuals’ general well-being, particularly in older adults. However, factors influencing QoL among older adults in low- and middle-income countries (LMICs) have not been fully examined. Furthermore, the role of gender differences in relation to QoL in multiple LMICs has also not been examined in detail.

Methods

This study used data from the World Health Organization’s Study on global AGEing and adult health (SAGE), Wave-1. Based on a literature review of existing works, a set of variables—an independent variable and covariates—were selected. The study sample consisted of 33,019 participants aged 50 years and above from China, Ghana, India, Russia, and South Africa. Multivariate linear regression models were estimated with the World Health Organization QoL scores as the dependent variable. To preserve the analytical sample size, multiple imputation was used to account for missing data.

Results

The results showed that generally, male older adults reported a better QoL than female older adults across all of the countries. The associations between QoL and sociodemographic factors, health-related factors, and social support factors among older adults differed according to country.

Conclusions

This study provides a better understanding of QoL among older adults in LMICs, which can help prepare LMICs to better address the QoL of older adults. The results of this study can be used to develop programs to promote better living standards and services to reduce gender disparities and ultimately, to improve the QoL among older adults in LMICs.

The impact of microbial keratitis on quality of life in Uganda

Background

Microbial keratitis (MK) is a frequent cause of sight loss in sub-Saharan Africa. However, no studies have formally measured its impact on quality of life (QoL) in this context.

Methods

As part of a nested case–control design for risk factors of MK, we recruited patients presenting with MK at two eye units in Southern Uganda between December 2016 and March 2018 and unaffected individuals, individually matched for sex, age and location. QoL was measured using WHO Health-Related and Vision-Related QoL tools (at presentation and 3 months after start of treatment in cases). Mean QoL scores for both groups were compared. Factors associated with QoL among the cases were analysed in a linear regression model.

Results

215 case-controls pairs were enrolled. The presentation QoL scores for the cases ranged from 20 to 65 points. The lowest QoL was visual symptom domain; mean 20.7 (95% CI 18.8 to 22.7) and the highest was psychosocial domain; mean 65.6 (95% CI 62.5 to 68.8). At 3 months, QoL scores for the patients ranged from 80 to 90 points while scores for the controls ranged from 90 to 100. The mean QoL scores of the cases were lower than controls across all domains. Determinants of QoL among the cases at 3 months included visual acuity at 3 months and history of eye loss.

Conclusion

MK severely reduces QoL in the acute phase. With treatment and healing, QoL subsequently improves. Despite this improvement, QoL of someone affected by MK (even with normal vision) remains lower than unaffected controls.

Mortality during 6 years of follow-up in relation to visual impairment and eye disease: results from a population-based cohort study of people aged 50 years and above in Nakuru, Kenya

OBJECTIVE

To estimate the association between (1) visual impairment (VI) and (2) eye disease and 6-year mortality risk within a cohort of elderly Kenyan people.

DESIGN, SETTING AND PARTICIPANTS

The baseline of the Nakuru Posterior Segment Eye Disease Study was formed from a population-based survey of 4318 participants aged ≥50 years, enrolled in 2007-2008. Ophthalmic and anthropometric examinations were undertaken on all participants at baseline, and a questionnaire was administered, including medical and ophthalmic history. Participants were retraced in 2013-2014 for a second examination. Vital status was recorded for all participants through information from community members. Cumulative incidence of mortality, and its relationship with baseline VI and types of eye disease was estimated. Inverse probability weighting was used to adjust for non-participation.

PRIMARY OUTCOME MEASURES

Cumulative incidence of mortality in relation to VI level at baseline.

RESULTS

Of the baseline sample, 2170 (50%) were re-examined at follow-up and 407 (10%) were known to have died (adjusted risk of 11.9% over 6 years). Compared to those with normal vision (visual acuity (VA) ≥6/12, risk=9.7%), the 6-year mortality risk was higher among people with VI (<6/18 to ≥6/60; risk=28.3%; risk ratio (RR) 1.75, 95% CI 1.28 to 2.40) or severe VI (SVI)/blindness (<6/60; risk=34.9%; RR 1.98, 95% CI 1.04 to 3.80). These associations remained after adjustment for non-communicable disease (NCD) risk factors (mortality: RR 1.56, 95% CI 1.14 to 2.15; SVI/blind: RR 1.46, 95% CI 0.80 to 2.68). Mortality risk was also associated with presence of diabetic retinopathy at baseline (RR 3.18, 95% CI 1.98 to 5.09), cataract (RR 1.26, 95% CI 0.95 to 1.66) and presence of both cataract and VI (RR 1.57, 95% CI 1.24 to 1.98). Mortality risk was higher among people with age-related macular degeneration at baseline (with or without VI), compared with those without (RR 1.42, 95% CI 0.91 to 2.22 and RR 1.34, 95% CI 0.99 to 1.81, respectively).

CONCLUSIONS

Visual acuity was related to 6-year mortality risk in this cohort of elderly Kenyan people, potentially because both VI and mortality are related to ageing and risk factors for NCD.

Quality of life and participation of young adults with a visual impairment aged 18-25 years: comparison with population norms

Purpose

To compare health‐related quality of life and participation of visually impaired young adults with normative groups, and to explore severity of vision loss and its association with participation and quality of life.

Methods

Young adults aged 18–25 years (n = 172) registered at two Dutch low vision rehabilitation organizations completed the Short Form Health Survey (SF‐36), EuroQol‐5 Dimensions (EQ‐5D), Impact on Participation and Autonomy (IPA) and Low Vision Quality of Life questionnaire (LVQOL). EQ‐5D and SF‐36 scores were compared to age‐specific norms. IPA scores were compared to norms of a population having three chronic diseases simultaneously. Linear regression was used to assess the association between severity of vision loss (mild VI, moderate VI and severe VI/blindness), and quality of life and participation.

Results

Participants scored significantly worse on almost all (sub)scales compared with relevant norms. Effect sizes for the EQ‐5D and SF‐36 (sub)scales were mostly small; moderate and large effect sizes were found for the IPA. Compared to young adults with mild VI, corrected models showed a significant association between having moderate VI and the physical component score of the SF‐36, and between severe VI/blindness and the LVQOL.

Conclusion

VI has a moderate impact on some aspects of quality of life and a large impact on participation of young adults when compared with relevant normative populations. Severity of vision loss is associated with worse physical functioning and vision‐related quality of life. The results contribute to a better understanding of the impact of VI and might lead to improved low vision services.

Seeing and hearing: The impacts of New York City's universal pre-kindergarten program on the health of low-income children

We examine the effect of New York City's universal pre-kindergarten program (UPK) on the health and utilization of children enrolled in Medicaid using a difference-in-regression-discontinuities design. We find that UPK increases the probability that a child is diagnosed with asthma or with vision problems, receives treatment for hearing or vision problems, or receives an immunization or screening during the pre-kindergarten year. These effects are not offset by lower rates in the kindergarten year, suggesting that UPK accelerates the rate at which children are identified with and treated for conditions that could potentially delay learning and cause behavioral problems.

The Impact of Trachomatous Trichiasis on Quality of Life: A Case Control Study

Background

Trachomatous trichiasis is thought to have a profound effect on quality of life (QoL), however, there is little research in this area. We measured vision and health-related QoL in a case-control study in Amhara Region, Ethiopia.

Methodology/Principal Findings

We recruited 1000 adult trichiasis cases and 200 trichiasis-free controls, matched to every fifth trichiasis case on age (+/- two years), sex and location. Vision-related quality of life (VRQoL) and health-related quality of life (HRQoL) were measured using the WHO/PBD-VF20 and WHOQOL-BREF questionnaires. Comparisons were made using linear regression adjusted for age, sex and socioeconomic status. Trichiasis cases had substantially lower VRQoL than controls on all subscales (overall eyesight, visual symptom, general functioning and psychosocial, p<0.0001), even in the sub-group with normal vision (p<0.0001). Lower VRQoL scores in cases were associated with longer trichiasis duration, central corneal opacity, visual impairment and poor contrast sensitivity. Trichiasis cases had lower HRQoL in all domains (Physical-health, Psychological, Social, Environment, p<0.0001), lower overall QoL (mean, 34.5 v 64.6; p<0.0001) and overall health satisfaction (mean, 38.2 v 71.7; p<0.0001). This association persisted in a sub-group analysis of cases and controls with normal vision. Not having a marriage partner (p<0.0001), visual impairment (p = 0.0068), daily labouring (p<0.0001), presence of other health problems (p = 0.0018) and low self-rated wealth (p<0.0001) were independently associated with lower overall QoL scores in cases. Among cases, trichiasis caused 596 (59%) to feel embarrassed, 913 (91.3%) to worry they may lose their remaining eyesight and 681 (68.1%) to have sleep disturbance.

Conclusions/Significance

Trachomatous trichiasis substantially reduces vision and health related QoL and is disabling, even without visual impairment. Prompt trichiasis intervention is needed both to prevent vision loss and to alleviate physical and psychological suffering, social exclusion and improve overall well-being. Implementation of the full SAFE strategy is needed to prevent the development of trachomatous trichiasis.

There is clear evidence that visual impairment generally reduces quality of life. However, relatively little is known about the impact that trachomatous trichiasis (TT) has on the lives of affected people with and without the presence of visual impairment. We measured the impact of TT on vision and health-related quality of life in 1000 people with TT using standard WHO quantitative tools and compared these with 200 trichiasis-free controls, matched to every fifth trichiasis case on age, sex and location. We found TT cases had lower vision and health related quality of life than controls regardless of visual impairment and other health problems suggesting the burden of TT goes beyond visual loss. The results provide solid data for advocacy and encourage programme leaders and funders to secure resources to promote trichiasis intervention. Trichiasis causes considerable physical and psychosocial trauma including sleep disturbance, low self-esteem and possibly a less stable marriage regardless of visual impairment. These suggest that, timely treatment is needed not only to prevent visual loss but also alleviate physical and psychological suffering and social exclusion of TT patients, thereby improving their physical and psychological health, general functioning and social relations.

Relationship between socioeconomic and lifestyle factors and cataracts in Koreans: the Korea National Health and Nutrition Examination Survey 2008-2011

PURPOSE

Cataracts are the leading cause of visual impairment and blindness, and therefore early identification and modification of the risk factors for cataracts are meaningful. This study aimed to investigate the relationship between socioeconomic status (SES) and lifestyle factors, and age-related cataracts in South Korea.

METHODS

This cross-sectional study was based on data collected in the 2008-2011 Korea National Health and Nutrition Examination Survey. A total of 15 866 subjects, aged ≥40 years, were included. SES was defined using household income and education level. Sociodemographic, lifestyle, and other associated factors were assessed by health interviews and examinations. Cataracts were diagnosed via slit-lamp examination using the Lens Opacities Classification System III.

RESULTS

The prevalence of any cataract was 38.9% in men and 42.3% in women (P<0.001). In women, the risk of cataracts increased with decreases in household income (P-value for trend=0.016 and 0.041 in any, and cortical cataract, respectively) and education level (P-value for trend=0.009, 0.027, and 0.016 in any, nuclear, and cortical cataract, respectively) after adjusting for confounding factors. Current smoking was correlated with nuclear cataracts in men (OR 1.21; 95% CI: 1.00, 1.46 in age-adjusted analysis) and cataract surgery in women (OR 2.25; 95% CI: 1.00, 5.04 in multivariate-adjusted analysis).

CONCLUSIONS

Socioeconomic disparities in cataract prevalence were observed in women; current smoking increased the risk of nuclear cataracts in men and surgery in women. Public health interventions focusing on gender differences are warranted to prevent and treat cataracts.

Rapid Assessment of Refractive Error, Presbyopia, and Visual Impairment and Associated Quality of Life in Nampula, Mozambique

Introduction

Uncorrected refractive error is the leading cause of visual impairment worldwide and leads to an impaired quality of life. This study was designed to determine the prevalence of uncorrected refractive error and presbyopia, to assess spectacle coverage, and to evaluate visual health-related quality of life among persons aged 15–50 years old in Nampula, Mozambique.

Methods

Participants were assessed using a validated rapid assessment of refractive error protocol, comprised of a demographic questionnaire, a standardized ophthalmic assessment to determine refractive status and spectacle coverage, and a modified vision-related quality of life questionnaire to assess the impact of uncorrected refractive error on participants’ visual health status.

Results

Among the 3,453 respondents, visual impairment prevalence was 3.5% (95%, CI 2.7%–4.2%), with 65.8% of those visually impaired being 35 years of age and older. Uncorrected refractive error prevalence was 2.6% (95%, CI 2.1–3.2%), and was the primary cause of visual impairment among 64.5% of cases. The spectacle coverage for uncorrected refractive error was 0%. Presbyopia prevalence was higher, at 25.8% (95%, CI 12.0–30.5%), with only 2.2% spectacle coverage. Respondents with visual impairment demonstrated statistically significantly lower quality of life scores compared to those without visual problems ( p < 0.01).

Implications for practitioners

The uncorrected refractive error problem and a distinct lack of spectacle coverage for refractive error and presbyopia indicate an urgent need for the development and delivery of a comprehensive refractive error service in the Nampula region of Mozambique.

Self-reported cataracts in older adults in Ghana: sociodemographic and health related factors

BACKGROUND

Changes in function of sensory organs with increasing age have significant impact on health and wellbeing of older persons. This paper describes cataract, a chronic eye condition, self-reported among older adults in Ghana and the need for improving access to eye care services.

METHODS

This work was based on the World Health Organization's multi-country Study on global AGEing and adult health (SAGE), conducted in six countries including Ghana. SAGE Wave 1 in Ghana was conducted in 2007-2008 in a nationally representative sample of 4278 older adults, ≥ 50 years. Data were obtained on sociodemographic and health factors related to self-reported cataracts in older persons in Ghana. Data were analysed using descriptive measures (frequencies and proportions), chi-square test for associations in categorical outcome measures, and logistic regression for predictors of cataracts with SPSS version 21.

RESULTS

Overall prevalence of self-reported cataracts among 4278 older adults in Ghana was 5.4%. Prevalence was proportionately higher for women (5.9%) than men (4.7%). Reported cataracts increased with age, among urban residents, in older adults living without partners and among those with the worse life satisfaction index. Older adults in lower income groups, poorly educated or living alone had difficulty seeking vision care services. Prevalence was 8.4% among persons with diabetes, 10.4% among hypertensives and 11.4% in persons with previous history of stroke. Among older persons who had ever used alcohol or tobacco, prevalence rates of reported cataracts were 5.7% and 4.9%, respectively. Logistic regression analysis indicated that increasing age, lower income status and self-reported hypertension were significantly associated with cataract among older adults in Ghana.

CONCLUSIONS

Cataract is prevalent in older people in Ghana with approximately 1 in 20 people aged 50 years or older reporting a previous diagnosis of cataract. As cataract surgery is restorative, a public health approach on behavioural modification, well structured national outreach eye care services (for rural residents), inclusion of basic eye health services at sub-district levels, increased family support and national health insurance for older persons is indicated.

Health burden associated with visual impairment in Singapore: the Singapore epidemiology of eye disease study

OBJECTIVE

To assess the impact of visual impairment (VI) on health-related quality of life and to compare the health burden of VI and other health conditions in Singapore.

DESIGN

Population-based cross-sectional study.

PARTICIPANTS

We studied the 10 009 adults (3353 Chinese, 3397 Indians, and 3259 Malays) who underwent a comprehensive eye assessment and completed the European Quality of Life-5 Dimensions (EQ-5D) questionnaire in the Singapore Epidemiology of Eye Disease Study.

METHODS

We estimated the effects of VI, obesity, hypertension, diabetes, and hyperlipidemia on the EQ-5D index score using linear regression models and the association between VI and self-reported EQ-5D health problems using logistic regression models. We compared prevalence-based quality-adjusted life-year (QALY) loss associated with VI and other health conditions. For each condition, QALY loss was calculated for 100 000 persons in 1 year using associated reduction in EQ-5D index score estimated in regression analysis as disutility.

MAIN OUTCOME MEASURES

The EQ-5D index score and annual QALY loss.

RESULTS

The EQ-5D index score decreased with increasing VI severity in all 3 ethnicities. For example, after adjusting for sociodemographic characteristics, the difference in EQ-5D index score between adults with bilateral severe VI and those without VI was -0.044 (95% confidence interval [CI], -0.089 to 0.001) in Chinese, -0.127 (95% CI, -0.237 to -0.017) in Indians, and -0.085 (95% CI, -0.148 to -0.022) in Malays. In all 3 ethnicities, VI was associated with reporting of problems in mobility (e.g., odds ratio [OR], 3.69 for Chinese with bilateral severe VI; 95% CI, 1.21-12.13) and usual activities (e.g., OR, 6.51 for Chinese with bilateral severe VI; 95% CI, 1.59-26.58). In Indians, VI was also associated with anxiety or depression (e.g., OR, 2.68 for bilateral severe VI; 95% CI, 1.11-6.50). The annual QALY loss associated with VI was 511.8 in Chinese, 608.8 in Indians, and 706.7 in Malays, greater than that associated with other health conditions examined in this study.

CONCLUSIONS

Visual impairment is associated with substantial health burden among Asians in Singapore. The relatively high burden of VI highlights the importance of VI prevention. The ethnic difference exhibited in this burden warrants further study.

The long term impact of cataract surgery on quality of life, activities and poverty: results from a six year longitudinal study in Bangladesh and the Philippines

Background

Cataract surgery has been shown to improve quality of life and household economy in the short term. However, it is unclear whether these benefits are sustained over time. This study aims to assess the six year impact of cataract surgery on health related quality of life (HRQoL), daily activities and economic poverty in Bangladesh and The Philippines.

Methods and Findings

This was a longitudinal study. At baseline people aged ≥50 years with visual impairment due to cataract (‘cases’) and age-, sex-matched controls without visual impairment were interviewed about vision specific and generic HRQoL, daily activities and economic indicators (household per capita expenditure, assets and self-rated wealth). Cases were offered free or subsidised cataract surgery. Cases and controls were re-interviewed approximately one and six years later. At baseline across the two countries there were 455 cases and 443 controls. Fifty percent of cases attended for surgery. Response rates at six years were 47% for operated cases and 53% for controls. At baseline cases had poorer health and vision related QoL, were less likely to undertake productive activities, more likely to receive assistance with activities and were poorer compared to controls (p<0.05). One year after surgery there were significant increases in HRQoL, participation and time spent in productive activities and per capita expenditure and reduction in assistance with activities so that the operated cases were similar to controls. These increases were still evident after six years with the exception that time spent on productive activities decreased among both cases and controls.

Conclusion

Cataract causing visual loss is associated with reduced HRQoL and economic poverty among older adults in low-income countries. Cataract surgery improves the HRQoL of the individual and economy of the household. The findings of this study suggest these benefits are sustained in the long term.

Utility of EQ-5D to assess patients undergoing cataract surgery

PURPOSE

To assess the construct validity and responsiveness of the EuroQoL-5D (EQ-5D) instrument in Asian patients undergoing cataract surgery in Singapore.

METHODS

In this prospective study, English- or Chinese-speaking patients (n = 216) completed the EQ-5D and the VF-14 questionnaires before and 3 months after they underwent cataract surgery. The impact of cataracts on patients was assessed using two standard gamble (SG) questions before surgery. Construct validity of the EQ-5D index and the visual analog scale (VAS) was assessed by examining their correlation with the VF-14 and SG scores. Responsiveness of the EQ-5D was compared with that of the VF-14 in terms of the magnitude of score change associated with cataract surgery.

RESULTS

We found that the EQ-5D index correlated with VF-14, SG (death), and SG (blindness) (Pearson r = 0.30, 0.23 and 0.24, respectively; p < 0.01). In contrast, we found no correlation between the EQ-VAS, VF-14, and SG scores. The mean EQ-5D index (difference, 0.06; effect size, 0.35) and VF-14 score (difference, 1.75; effect size, 0.97) of patients improved after cataract surgery (p < 0.0001).

CONCLUSIONS

Our study demonstrated that the EQ-5D utility index is a valid and responsive outcome measure for evaluating the impact of cataract surgery in our Asian population. However, the implications of using the generic EQ-5D instrument to assess the cost-effectiveness of surgical interventions for visual impairment require further investigation.

The impact of cataract, cataract types, and cataract grades on vision-specific functioning using Rasch analysis

PURPOSE

To determine the impact of cataracts and their types and grades on vision-specific functioning.

DESIGN

Prospective population-based cross-sectional study.

METHODS

The Singapore Indian Eye Study examined 3400 of 4497 (75.6% response rate) ethnic Indians 40 years of age and older living in Singapore. Three thousand one hundred sixty-eight (93.2%) fulfilled inclusion criteria with complete information for final analysis. Cataracts were assessed on slit-lamp examination and were graded according to the Lens Opacity Classification System III. Vision-specific functioning scores were explored with the Visual Function scale, validated using Rasch analysis.

RESULTS

Two hundred sixty-nine (8.5%) and 740 (23.4%) of the study participants had unilateral and bilateral cataracts, respectively, and 329 (10.4%), 800 (25.2%), and 128 (4.1%) participants had nuclear, cortical, and posterior subcapsular (PSC) cataracts, respectively. In multivariate linear regression models, the presence of bilateral rather than unilateral cataract (β = -0.12; 95% confidence interval, -0.20 to 0.00) was associated independently with poorer vision-specific functioning, even after adjusting for undercorrected refractive error (β = -0.11; 95% confidence interval, -0.21 to 0.00). Bilateral nuclear, cortical, and PSC cataracts also were associated with poorer vision-specific functioning (β = -0.31, -0.15, and -1.15, respectively), with combinations of them having even greater impact. Significantly poorer vision-specific functioning occurred at Lens Opacity Classification System grades 4 (nuclear opalescence), 5 (nuclear color), 3 (cortical), and 1 (PSC) or higher.

CONCLUSIONS

People with bilateral but not unilateral cataracts experience difficulty with performing vision-specific daily activities independent of refractive error, with PSC cataracts and cataract combinations having the greatest impact. Cataract types cause poorer vision-specific functioning beginning at different severity grades.

Validity of EuroQOL-5D, time trade-off, and standard gamble for age-related macular degeneration in the Singapore population

BACKGROUND/AIMS

Utility values of age-related macular degeneration (AMD) in Asian patients are unknown. This study aims to assess utility values and construct validity of the EuroQOL-5D (EQ-5D), time trade-off (TTO), and standard gamble (SG) instruments in the Singapore multi-ethnic AMD population.

METHODS

Cross-sectional, two-centre, institution-based study. Visual acuity (VA), clinical AMD severity, and utility scores on the EQ-5D, TTO, and SG were obtained from 338 AMD patients. VA was analysed in terms of the better-seeing eye (BEVA), worse-seeing eye (WEVA), and weighted average of both eyes (WVA). We evaluated SG on the perfect health-death (SG(death)) and binocular perfect vision-binocular blindness (SG(blindness)) scales. Construct validity was determined by testing a priorihypotheses relating the EQ-5D, TTO, and SG utility scores to VA and clinical AMD severity.

RESULTS

The mean utilities on the EQ-5D, TTO, SG(death), and SG(blindness) were 0.89, 0.81, 0.86, and 0.90, respectively. EQ-5D scores correlated weakly with BEVA, WEVA, and WVA (Pearson's correlation coefficients -0.291, -0.247, and -0.305 respectively, P<0.001 for all). SG(death) and SG(blindness) demonstrated no correlation with BEVA, WEVA, or WVA (Pearson's correlation coefficients, range -0.06 to -0.125). TTO showed weak association only with WEVA and WVA (correlation coefficients -0.237, -0.228, P<0.0001), but not with BEVA (correlation coefficient -0.161). Clinical AMD severity correlated with EQ-5D and SG(death), but not with TTO and SG(blindness) (P=0.004, 0.002, 0.235, and 0.069, respectively).

CONCLUSIONS

AMD has a negative impact on utilities, although utility scores were high compared with Western cohorts. EQ-5D, TTO, and SG showed suboptimal construct validity, suggesting that health status utilities may not be sufficiently robust for cost-utility analyses in this population.

A review of generic preference-based measures of health-related quality of life in visual disorders

OBJECTIVE

This review examines generic preference-based measures and their ability to reflect health-related quality of life in patients with visual disorders.

METHODS

A systematic search was undertaken to identify clinical studies of patients with visual disorders where health state utility values were measured and reported. Data were extracted to assess the validity and responsiveness of the measures. A narrative synthesis of the data was undertaken due to the heterogeneity between different studies.

RESULTS

There was considerable heterogeneity in the 31 studies identified in terms of patient characteristics, visual disorders, and outcomes reported. Vision loss was associated with a reduction in scores across the preference-based measure, but the evidence on validity and responsiveness was mixed. The EQ-5D health-related assessment instrument's performance differed according to condition, with poor performance in age-related macular degeneration (AMD) and diabetic retinopathy. The more limited evidence on the HUI-3 instrument found it performed best in differentiating between severity groups of patients with glaucoma, AMD, cataracts, and diabetic retinopathy. One study reported data on the SF-6D instrument and showed it was able to differentiate between patients with AMD.

CONCLUSIONS

The performance of the EQ-5D in visual disorders was mixed. The HUI-3 seemed to perform better in some conditions, but the evidence on this and SF-6D is limited. More head to head comparisons of these three measures are required. The new five-level version of EQ-5D may do better at the milder end of visual function.

Does cataract surgery alleviate poverty? Evidence from a multi-centre intervention study conducted in Kenya, the Philippines and Bangladesh

Background

Poverty and blindness are believed to be intimately linked, but empirical data supporting this purported relationship are sparse. The objective of this study is to assess whether there is a reduction in poverty after cataract surgery among visually impaired cases.

Methodology/Principal Findings

A multi-centre intervention study was conducted in three countries (Kenya, Philippines, Bangladesh). Poverty data (household per capita expenditure – PCE, asset ownership and self-rated wealth) were collected from cases aged ≥50 years who were visually impaired due to cataract (visual acuity<6/24 in the better eye) and age-sex matched controls with normal vision. Cases were offered free/subsidised cataract surgery. Approximately one year later participants were re-interviewed about poverty. 466 cases and 436 controls were examined at both baseline and follow-up (Follow up rate: 78% for cases, 81% for controls), of which 263 cases had undergone cataract surgery (“operated cases”). At baseline, operated cases were poorer compared to controls in terms of PCE (Kenya: $22 versus £35 p = 0.02, Bangladesh: $16 vs $24 p = 0.004, Philippines: $24 vs 32 p = 0.0007), assets and self-rated wealth. By follow-up PCE had increased significantly among operated cases in each of the three settings to the level of controls (Kenya: $30 versus £36 p = 0.49, Bangladesh: $23 vs $23 p = 0.20, Philippines: $45 vs $36 p = 0.68). There were smaller increases in self-rated wealth and no changes in assets. Changes in PCE were apparent in different socio-demographic and ocular groups. The largest PCE increases were apparent among the cases that were poorest at baseline.

Conclusions/Significance

This study showed that cataract surgery can contribute to poverty alleviation, particularly among the most vulnerable members of society. This study highlights the need for increased provision of cataract surgery to poor people and shows that a focus on blindness may help to alleviate poverty and achieve the Millennium Development Goals.

Visual impairment from cataract and health related quality of life: results from a case-control study in the Philippines

PURPOSE

To evaluate a vision related quality of life (VRQoL) scale, the World Health Organization Prevention of Blindness and Deafness Visual Function-20 (WHO/ PBD VF20) and describe the relationship between visual impairment from cataract and vision related and generic Health Related Quality of Life (HRQoL) in a case-control study of adults aged > or = 50 years in the Philippines.

METHODS

Two hundred and thirty eight population based persons visually impaired from cataract and 163 age- gender- matched controls with normal vision were interviewed using the WHO/PBD VF20 and European Quality of Life (EuroQol) questionnaire (an HRQoL). The WHO/PBD VF20 was evaluated using standard psychometric tests.

RESULTS

The WHO/PBD VF20 had good item acceptability and validity. Cases had significantly poorer VRQoL than controls and worsening Visual Acuity (VA) was associated with worsening VRQoL. The general functioning subscale had good internal consistency. The psychosocial sub-scale had a Cronbach's alpha of 0.61, just below the generally accepted criteria of 0.70. Cases were much more likely than controls to report problems with the Euroqol five descriptive domains (EQ-5D)and had significantly poorer self-rated health.

CONCLUSIONS

The study supports the use of the WHO/PBD VF20 in a Philippine population and highlights the worsening VRQoL associated with cataract vision loss. The poorer generic HRQoL among cases compared to controls indicates an impact of visual impairment on perceived health and well-being, beyond vision-specific experience.

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.

The impact of cataract surgery on activities and time-use: results from a longitudinal study in Kenya, Bangladesh and the Philippines

Background

Cataract is the leading cause of blindness in the world, and blindness from cataract is particularly common in low-income countries. The aim of this study is to explore the impact of cataract surgery on daily activities and time-use in Kenya, Bangladesh and the Philippines.

Methods/Principal Findings

A multi-centre intervention study was conducted in three countries. Time-use data were collected through interview from cases aged ≥50 years with visually impairing cataract (VA <6/24) and age- and gender-matched controls with normal vision (VA≥6/18). Cases were offered free/subsidized cataract surgery. Approximately one year later participants were re-interviewed about time-use. At baseline across the three countries there were 651 cases and 571 controls. Fifty-five percent of cases accepted surgery. Response rate at follow up was 84% (303 out of 361) for operated cases, and 80% (459 out of 571) for controls. At baseline, cases were less likely to carry out and spent less time on productive activities (paid and non-paid work) and spent more time in “inactivity” compared to controls. Approximately one year after cataract surgery, operated cases were more likely to undertake productive activities compared to baseline (Kenya from 55% to 88%; Bangladesh 60% to 95% and Philippines 81% to 94%, p<0.001) and mean time spent on productive activities increased by one-two hours in each setting (p<0.001). Time spent in “inactivity” in Kenya and Bangladesh decreased by approximately two hours (p<0.001). Frequency of reported assistance with activities was more than halved in each setting (p<0.001).

Conclusions/Significance

The empirical evidence provided by this study of increased time spent on productive activities, reduced time in inactivity and reduced assistance following cataract surgery among older adults in low-income settings has positive implications for well-being and inclusion, and supports arguments of economic benefit at the household level from cataract surgery.