The NEI VFQ-25C: Calibrating Items in the National Eye Institute Visual Function Questionnaire-25 to Enable Comparison of Outcome Measures

Vision degrading myodesopsia from vitreous floaters in the young: An important aspect of myopia

Vitreous floaters are visual phenomena resulting from floating opacities inside the eye that disturb vision. The opacities consist of microscopic collagen fibers that aggregate in myopia and during aging. These collagen fibers are then seen as irregular, sometimes worm-like shadows or structures of a translucent to black color. Because of the floating aspect, they tend to follow the movements of the eye, causing distress and having a negative impact on a patient's quality of life due to degradation in contrast sensitivity function. This is referred to as vision degrading myodesopsia (VDM). The overall importance of floaters and their effect on quality of life gained attention in recent years. While the existence of floaters alone is labeled as harmless, there is an increasing group of young people suffering from VDM. This coincides with the growing prevalence of myopia. Indeed, myopia and myopic vitreopathy are the major causes of VDM in the young. This aspect of myopia, however, is often overlooked. We review the current research status in floater formation, quality of life impact, symptom assessment, localization and therapeutic options for vitreous floaters from the perspective of a myopic, potentially younger patient group.

Estimating Visual Acuity Without a Visual Acuity Chart

Purpose

This study explored whether visual acuity (VA) can be inferred from self-reported ability to recognize everyday objects using a set of yes/no questions.

Methods

Participants answered 100 yes/no questions designed to assess their ability to recognize familiar objects at typical viewing distances, such as distinguishing between a full moon and a half moon on a clear night. The questions demanded VA ranging from normal to severe vision impairment. Responses were analyzed using item response theory, and the results were compared with participants' VA values.

Results

We recruited 385 participants from 4 sites in the United States. Participants had a mean age of 56.7 years with VA ranging from -0.3 to 2.0 logarithm of the minimum angle of resolution (logMAR) (mean = 0.58). A strong relationship was observed between participants' estimated vision ability and their VA (r = -0.72). The linear relationship can be used to predict each participant's VA based on their estimated vision ability. The average signed and unsigned prediction errors were 0 and 0.24 logMAR, respectively, with a coefficient of repeatability of 0.59 logMAR between the estimated VA and measured VA. The same linear function was used to determine the VA limit required for each question. For instance, the VA limit for the moon question was 1.0 logMAR.

Conclusions

Yes/no questions about everyday visual activities have the potential to estimate an individual's VA. Future refinements may enhance reliability.

Translational Relevance

The survey provides insights into the real-world visual capabilities of people with low vision, making it potentially useful for telehealth applications.

Clinical outcome measures in vision and eye care

Traditionally, clinical outcome assessments have focused on the patient's perspective through patient-reported outcome assessments; however, given the complexity, integration, and interactions of various participants within the clinical ophthalmology setting, we propose that additional diverse clinical perspectives should be explored in order to appreciate fully the value of care provided to patients. In this review we introduce a framework by which clinical outcome assessments (COAs) can be organized. Our COA framework is composed of five outcome measurements that encompass the perspectives of each player in a patient's care: clinical data-reported outcomes, patient-reported outcomes, clinician-reported outcomes, observer-reported outcomes, and reviewer-reported outcomes. By establishing a standard for evaluating patient care, we hope to address gaps in expectations of patient care and encourage more thoughtful patient-clinician relationships.

Vision-related quality of life after unilateral occipital stroke

BACKGROUND/OBJECTIVES

Stroke damage to the primary visual cortex induces large, homonymous visual field defects that impair daily living. Here, we asked if vision-related quality of life (VR-QoL) is impacted by time since stroke.

SUBJECTS/METHODS

We conducted a retrospective meta-analysis of 95 occipital stroke patients (female/male = 26/69, 27-78 years old, 0.5-373.5 months poststroke) in whom VR-QoL was estimated using the National Eye Institute Visual Functioning Questionnaire (NEI-VFQ) and its 10-item neuro-ophthalmic supplement (Neuro10). Visual deficit severity was represented by the perimetric mean deviation (PMD) calculated from 24-2 Humphrey visual fields. Data were compared with published cohorts of visually intact controls. The relationship between VR-QoL and time poststroke was assessed across participants, adjusting for deficit severity and age with a multiple linear regression analysis.

RESULTS

Occipital stroke patients had significantly lower NEI-VFQ and Neuro10 composite scores than controls. All subscale scores describing specific aspects of visual ability and functioning were impaired except for ocular pain and general health, which did not differ significantly from controls. Surprisingly, visual deficit severity was not correlated with either composite score, both of which increased with time poststroke, even when adjusting for PMD and age.

CONCLUSIONS

VR-QoL appears to improve with time postoccipital stroke, irrespective of visual deficit size or patient age at insult. This may reflect the natural development of compensatory strategies and lifestyle adjustments. Thus, future studies examining the impact of rehabilitation on daily living in this patient population should consider the possibility that their VR-QoL may change gradually over time, even without therapeutic intervention.

Evaluation of dietary patterns and their impact on eye health among Saudi adults-A multi-regional cross-sectional analysis in Makkah, Riyadh, and Qassim

Background and aim

Nutrition plays a vital role in maintaining and improving vision health. However, little is known about dietary intake habits and their correlation with vision health among adults in the Kingdom of Saudi Arabia (KSA). The present survey was aimed to assess dietary patterns and vision health among Saudi adults and to determine the association between dietary patterns and vision health.

Methods

The present analytical study was carried out among 1,234 Saudi adults in the Makkah, Riyadh, and Qassim regions of KSA. We used the Arabic version of the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) and the diet quality screener (DQS). We applied Mann-Whitney U and Kruskal-Wallis tests to determine the association between vision function score and demographic characteristics. Furthermore, the Spearman correlation test was used to determine the relationship between the DQS and the NEI VFQ-25.

Results

Of the studied population, the highest score obtained through the NEI VFQ-25 was in the social function domain (mean ± SD = 76.64 ± 18.63), followed by the general vision domain (mean ± SD = 75.21 ± 15.16) and was negatively correlated with age. Regarding dietary patterns, the intake of lean protein sources per week was the highest, with a mean intake of 4.17 days per week, followed by that of whole grains and milk or dairy products, with a mean intake of around four days per week. There was a significant correlation between various dietary intakes and visual function scores.

Conclusion

The present survey underscores the significance of understanding regional dietary patterns and their implications for vision health. Furthermore, our study's findings indicate a need for targeted nutritional intervention measures to improve the vision health of this population.

Quality of life in patients with CRB1-associated retinal dystrophies: A longitudinal study

PURPOSE

To assess the longitudinal vision-related quality of life among patients with CRB1-associated inherited retinal dystrophies.

METHODS

In this longitudinal questionnaire study, the National Eye Institute Visual Function Questionnaire (39 items, NEI VFQ-39) was applied at baseline, two-year follow-up, and 4-year follow-up in patients with pathogenic CRB1 variants. [Correction added on 20 November 2023, after first online publication: The preceding sentence has been updated in this version.] Classical test theory was performed to obtain subdomain scores and in particular 'near activities' and 'total composite' scores. The Rasch analysis based on previous calibrations of the NEI VFQ-25 was applied to create visual functioning and socio-emotional subscales.

RESULTS

In total, 22 patients with a CRB1-associated retinal dystrophy were included, […] with a median age of 25.0 years (interquartile range: 13-31 years) at baseline and mean follow-up of 4.0 ± 0.3 years. [Correction added on 20 November 2023, after first online publication: The preceding sentence has been updated in this version.] A significant decline at 4 years was observed for 'near activities' (51.0 ± 23.8 vs 35.4 ± 14.7, p = 0.004) and 'total composite' (63.0 ± 13.1 vs 52.0 ± 12.1, p = 0.001) subdomain scores. For the Rasch-scaled scores, the 'visual functioning' scale significantly decreased after 2 years (-0.89 logits; p = 0.012), but not at 4-year follow-up (+0.01 logits; p = 0.975). [Correction added on 20 November 2023, after first online publication: In the preceding sentence, "…after 4 years…" has been corrected to "…after 2 years…" in this version.] The 'socio-emotional' scale also showed a significant decline after 2 years (-0.78 logits, p = 0.033) and 4 years (-0.83 logits, p = 0.021).

CONCLUSION

In the absence of an intervention, a decline in vision-related quality of life is present in patients with pathogenic CRB1 variants at 4-year follow-up. Patient-reported outcome measures should be included in future clinical trials, as they can be a potential indicator of disease progression and treatment efficacy.

Piloting Rasch model scoring of the National Eye Institute Visual Function Questionnaire in uveitis

INTRODUCTION

The National Eye Institute Visual Function Questionnaire (NEI VFQ) is a common patient-reported outcome measure (PROM) in uveitis trials. Its psychometric properties using state-of-the-art scoring based on Rasch models, a latent trait model that improves accuracy of PROMs assessment, has not yet been investigated.

METHODS

The study participants were recruited online from uveitis patient organizations, where individuals self-reported their uveitis diagnosis and visual acuity level. These participants then completed the NEI VFQ-25. The visual function (VF) and socioemotional (SE) subscales were psychometrically analysed in terms of item fit, targeting, internal consistency, dimensionality, and differential item functioning (DIF), using Rasch models. Criterion validity was examined based on associations between NEI VFQ person measures and recent visual acuity (VA) levels.

RESULTS

Ninety-nine participants recruited online from uveitis patient organizations (68 women, 31 men; mean age 50 ± 15 years; 46.5% self-reported receiving systematic therapy for uveitis, 0.6% NEI VFQ-25 missing data) were included. The mean difficulty of items was lower than the average person ability. None of the items demonstrated misfit to an extent that would induce noise into the measurement. The consistency metrics person reliability and person separation index of the subscales were 0.85 and 2.34 (NEI VFQ-VF), 0.86 and 2.52 (NEI VFQ-SE), respectively. There was no evidence of multidimensionality and none of the items showed DIF by gender. The differences between item and person measures were 1.44 (NEI VFQ-VF) and 1.03 (NEI VFQ-SE). NEI VFQ-25 person measures were significantly lower in participants with visual impairment (all p values ≤ 0.007).

CONCLUSION

Rasch model-based scoring of the re-engineered NEI VFQ-25 demonstrates acceptable internal consistency, item fit and construct validity for assessing two key domains of quality of life in individuals self-reporting uveitis. The PROM was targeted at a higher level of difficulty than present in our heterogeneous sample.

Validation of the brain injury associated visual impairment - impact questionnaire (BIVI-IQ)

PURPOSE

The Brain Injury associated Visual Impairment - Impact Questionnaire (BIVI-IQ) was developed to assess the impact of post-stroke visual impairment. The development of the questionnaire used robust methods involving stroke survivors and clinicians. The aim of this study was to assess the validity of the BIVI-IQ in a stroke population.

METHODS

Stroke survivors with visual impairment were recruited from stroke units, outpatient clinics and non-healthcare settings. Participants were asked to complete questionnaire sets on three separate occasions; the BIVI-IQ at each visit with additional questionnaires at baseline and visit 2. Vision assessment and anchor questions from participants and clinicians were collected. The analysis included assessment of missing data, acceptability, Rasch model analysis, test-retest reliability, construct validity (NEI VFQ-25, EQ-5D-5L) and responsiveness to change.

RESULTS

316 stroke survivors completed at least one questionnaire of the 326 recruited. Mean age was 67 years and 64% were male. Adequate fit statistics to the Rasch model were reached (χ2 = 73.12, p = 0.02) with two items removed and thresholds of two adjusted, indicating validity and unidimensionality. Excellent test-retest reliability was demonstrated (ICC = 0.905) with a 3-month interval. Construct validity was demonstrated with a strong significant correlation to the NEI VFQ-25 (r = 0.837, p < 0.01). The BIVI-IQ also demonstrated responsiveness to change with significant differences identified between groups based on participant and clinician anchor questions (X2 = 23.29, p < 0.001; X2 = 24.56, p < 0.001).

CONCLUSION

The BIVI-IQ has been shown to be valid and practical for 'everyday' use by clinicians and researchers to monitor vision-related quality of life in stroke survivors with visual impairment.

Measurement of visual functioning following first and second eye cataract surgery using Vision-Related Activity Limitation Item Bank

PURPOSE

This study aims to compare visual functioning (VF) after first or second eye cataract surgery using the vision-related activity limitation (VRAL) item bank.

METHODS

This prospective, interventional study included 787 patients (mean age, 58.2 years) with cataract undergoing cataract surgery (first eye surgery with/out ocular comorbidity, second eye surgery with/out ocular comorbidity) at a tertiary eye care center, South India, who were administered the item bank pre- and at 6 weeks postoperatively to assess change in VF. Rasch analysis was used to estimate VF at both time points, and responsiveness to cataract surgery was calculated as effect size (ES) which was interpreted as small (≤ 0.2), moderate (0.3-0.7), and large (≥ 0.8).

RESULTS

Mean best-corrected logMAR VA in surgical eye improved significantly postoperatively compared to preoperative VA (0.20 ± 0.40 vs. 1.19 ± 0.96; P < 0.0001) across all groups. Patients reported significant and large improvements in VF postoperatively across all groups: largest ES for first eye surgery without comorbidity (1.87 [95% CI, 1.61, 2.13]) and smallest for second eye without ocular comorbidity (1.55 [95% CI, 1.22, 1.88]). Compared to patients undergoing second eye surgery, first eye surgery patients reported significantly lower VF preoperatively (-0.72 ± 2.39 vs. 0.17 ± 2.34 logits; P < 0.0001), and a larger change in VF postoperatively (3.71 ± 2.33 logits vs. 4.27 ± 2.83 vs.; P = 0.004).

CONCLUSIONS

Cataract surgery resulted in large and significant improvements in VF, regardless of ocular comorbidity and first or second eye surgery. The VRAL item bank is a useful tool to measure responsiveness to cataract surgery.

Measuring Quality of Life in Diabetic Retinal Disease: A Narrative Review of Available Patient-Reported Outcome Measures

Topic

Several patient-reported outcome measures (PROMs) are available to measure health-related quality of life (HRQoL) in patients with late-stage clinical diabetic retinal diseases (DRDs). However, an understanding of the psychometric properties of PROMs is needed to assess how they could relate to severity levels of a revised DRD grading system. This narrative review assessed the available generic-, vision-, and DRD-related PROMs used in DRD research and highlights areas for improvement.

Clinical Relevance

Diabetic retinal disease is a common complication of diabetes and can lead to sight-threatening complications with a devastating effect on HRQoL.

Methods

The Quality of Life working group is one of 6 working groups organized for the DRD Staging System Update Effort, a project of the Juvenile Diabetes Research Foundation Mary Tyler Moore Vision Initiative. PubMed, Cochrane Library, Embase, and Google Scholar databases were searched using core keywords to retrieve ophthalmology-related review articles, randomized clinical trials, and prospective, observational, and cross-sectional studies in the English language. A detailed review of 12 PROMs (4 QoL questionnaires and 8 utilities) that met a minimum level of evidence (LOE) was conducted. The relevance of each PROM to DRD disease stage and Biomarker Qualification guidelines (Biomarkers, EndpointS, and other Tools) categories was also defined.

Results

The National Eye Institute 25-item Visual Function Questionnaire (NEI VFQ-25), Impact of vision impairment-computerized adaptive testing, and Diabetic Retinopathy and Macular Edema Computerized Adaptive Testing System had a LOE of II in detecting change due to late-stage DRD (diabetic macular edema), although several areas for improvement (e.g., psychometrics and generalizability) were identified. Other PROMs, particularly the utilities, had a LOE of III due to cross-sectional evidence in late-stage clinical DRD. Although the NEI VFQ-25 has been the most widely used PROM in late-stage DRD, more work is required to improve its multidimensional structure and other psychometric limitations. No PROM was deemed relevant for subclinical or early/mid-DRD.

Conclusion

This narrative review found that the most commonly used PROM is NEI VFQ-25, but none meets the ideal psychometric, responsiveness, and clinical setting digital administration requirements that could be included in an updated DRD staging system for diagnosis and monitoring of DRD progression.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Patient-reported outcomes of serum eye drops manufactured from Australian blood donations and packaged using Meise vials

Introduction

Serum eye drops (SED) are an effective treatment for dry eye syndrome. However, autologous serum collection can have challenges. Patient-tailored (allogeneic) SED (PT-SED) can be made from healthy blood donors. Australian Red Cross Lifeblood has manufactured both autologous SED (Auto-SED) and PT-SED and, in May 2021, introduced Meise vial packaging. This study aimed to explore SED patient-reported outcomes and vial packaging satisfaction.

Methods

A prospective cohort study was conducted with recruitment between 1 November 2021 and 30 June 2022. Participants completed the dry eye questionnaire (DEQ5), health-related quality-of-life (SF-8™), functional assessment of chronic illness therapy-treatment satisfaction-general (FACIT-TS-G), and general wellbeing surveys. Existing patients completed these once, and new patients were surveyed at baseline, 3 months post-treatment, and 6 months post-treatment.

Results

Participants who completed all study requirements were 24 existing and 40 new Auto-SED and 10 existing and 8 new PT-SED patients. Auto-SED patients were younger [56.2 (±14.7) years] than PT-SED patients [71.4 (±10.0) years]. Participants used a mean of 1.8 (±1.1) SED, 5.3 (±2.9) times per day. In new patients, DEQ5 scores improved within 6 months from 14.0 (±2.9) to 10.6 (±3.4) for Auto-SED and from 12.9 (±3.7) to 11.4 (±2.8) for PT-SED. General wellbeing measures improved in the new Auto-SED from 7.0 (±1.9) to 7.8 (±1.7) but were reduced for new PT-SED from 6.7 (±2.9) to 6.1 (±2.9).

Discussion

SED improved dry eye symptoms in most patients, regardless of the serum source. Patients using PT-SED showed decreases in some quality-of-life measures; however, recruitment was reduced due to operational constraints, and concurrent comorbidities were not assessed. General feedback for SED and vial packaging was positive, with some improvements identified.

Vision-Related Quality of Life Among Healthy, Preperimetric Glaucoma, and Perimetric Glaucoma Patients

PURPOSE

To investigate the association of vision-related quality of life (VRQOL) with the central visual field and macular ganglion cell complex (GCC) thickness in healthy control participants, patients with preperimetric glaucoma, and patients with perimetric glaucoma.

DESIGN

Retrospective cross-sectional study.

METHODS

A total of 39 healthy, 34 preperimetric glaucoma, and 145 perimetric glaucoma patients completed the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ). A linear mixed-effect models was used to investigate the association between the glaucoma stage as measured by binocular 10-2 visual field mean sensitivity (VFMS) and GCC thickness with the Rasch-calibrated NEI-VFQ score.

RESULTS

A total of 436 eyes from 218 participants (mean age = 67.2 [95% CI = 65.1 to 69.2] years) were enrolled. VRQOL calculated by the NEI-VFQ Rasch-calibrated score was worst for patients with perimetric glaucoma (50.7 [95% CI = 47.2 to 54.2]), followed by patients with preperimetric glaucoma (41.2 [95% CI = 34.5 to 47.9]) and healthy controls (29.3 [95% CI = 24.0 to 34.7]. Worse VRQOL had a moderate association with a worse global binocular 10-2 VFMS (-3.4 [95% CI = -5.0 to -1.9] dB per 1 score; P < .001; adjusted R² = 0.27), but not with a thinner global GCC in the better eye (-0.1 [95% CI = -0.2 to 0.1] µm per 1 score; P =.0485; adjusted R² = 0.17).

CONCLUSIONS

These findings suggest that patients with perimetric and preperimetric glaucoma have worse VRQOL than patients with healthy eyes. As compared to macular thickness measurements, the central visual field is more strongly associated with VRQOL and may better help to identify patients in need of intervention.