The Association of Health-Related Quality of Life with Severity of Visual Impairment among People Aged 40-64 Years: Findings from the 2006-2010 Behavioral Risk Factor Surveillance System

Characterization and prevalence of ocular comorbidities and risk of legal blindness across the United States

BACKGROUND/OBJECTIVES

Vision loss is a top disability in the United States (US). Patients commonly present with multiple ocular diseases, but the extent to which this places them at risk for vision loss, and if sex and race impacts this, is poorly understood. This exploratory analysis evaluated which ocular comorbidities and demographics are at highest risk for visual impairment.

SUBJECTS/METHODS

A retrospective cross-sectional study was conducted through the TriNetX Analytics Network, an aggregated network encompassing over 90 million insured and uninsured patients across 50 healthcare organizations from all regions in the US. Patients with diabetic retinopathy (DR), age-related macular degeneration (AMD), retinal vein occlusion (RVO), glaucoma, and uveitis were included in this study. Ocular diseases and visual impairment were determined through ICD-10 codes. Prevalence and odds ratios were calculated while stratifying by sex and racial demographics. Statistical analyses were completed using RStudio and Excel with 95% confidence intervals calculated.

RESULTS

The comorbid conditions with the highest prevalence of visual impairment were uveitis and RVO (39.94%), uveitis and neovascular AMD (37.61%), and uveitis and glaucoma (33.23%). The comorbidity with the highest odds for visual impairment was uveitis and RVO (POR 4.86; 95% CI 4.49, 5.26). Compared to white males, Black and Hispanic males were disproportionately affected by visual impairment across ocular comorbidities.

CONCLUSION

This study quantified the prevalence and odds of visual impairment for unilateral and comorbid ocular disease, with the addition of uveitis causing the greatest increase. Black and Hispanic males were disproportionately affected by visual impairment across comorbid conditions.

Relationship between physical and psychological functioning and health-related quality of life in congenital Aniridia

PURPOSE

Congenital aniridia is a serious eye disease characterized by absence of iris to various degrees. The aims of this study were to investigate health-related quality of life (HRQoL) in adults with aniridia and assess the relationships between HRQoL, psychological status, ocular health and obesity.

METHODS

Twenty-nine adults with congenital aniridia (48% male, aged 18-79 years) participated. HRQoL was measured with SF-36 and the EQ visual analogue scale (VAS). The physical (PCS) and mental (MCS) component summaries of the SF-36 were calculated with higher scores indicating better HRQoL. Symptoms of anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS). Obesity was assessed with the Patient-Reported Outcomes in Obesity (PROS). Sociodemographic characteristics, genetic variants and ocular and medical health variables were also analysed.

RESULTS

The participants scored significantly lower in the general health domain of the SF-36 than the general population (65.2 vs. 75.3, p = 0.017). The EQ VAS score was also lower in the aniridia group (64.9 vs. 77.9, p = 0.021). Low PCS score was correlated with presence of ocular pain (p = 0.019), high HADS score (p = 0.017) and high PROS score (p = 0.009). Low MCS score was related to higher educational level (p = 0.038) and high HADS score (p < 0.001). High HADS and PROS scores were both related to low EQ VAS scores.

CONCLUSION

Adults with congenital aniridia scored worse on certain measures of HRQoL than the general population. Poorer HRQoL was associated with increased symptoms of anxiety, depression and obesity and with presence of ocular pain.

The Risk of Cardiovascular Disease Risk Among Adults with Vision Impairment from Low-, Middle- and High-Income Countries

PURPOSE

The limited evidence for cardiovascular disease (CVD) among adults with vision impairment (VI) has often been from developed countries using self-reported VI. This study evaluated the association of objectively-determined VI with the risk of CVD among adults from low-, middle-, and high-income countries.

METHODS

Data were from 32,268 adults aged 30-74 years without CVD or blindness from China, Ghana, India, Mexico, Russian Federation, South Africa, and the United States during 2007-2010. VI and severe VI was defined as presenting visual acuity worse than 6/18, and 6/60, respectively. The Framingham risk algorithm was used to estimate the risk for incident CVD. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals.

RESULTS

The mean age of participants was 46.4 years, with half of them being women (49.3%). The age-adjusted prevalence of VI ranged from 1.1% (United States) to 14.2% (South Africa) while severe VI ranged from 0.4% (United States) to 4.5% (Ghana). In models adjusting for country, sociodemographic factors, waist girth, healthcare use, activities of daily living and other health-related factors, VI was associated with CVD risk ≥ 10% (OR = 1.69, 95% CI: 1.22-2.36). This observed association was largely consistent across countries (p = 0.119). The observed CVD risk was similar among adults with moderate or severe VI (OR = 0.95, 95% CI: 0.50-1.83). CVD risk was higher among adults with VI who were <65 years old (OR = 1.89, 95% CI: 1.36-2.63) or were employed (OR = 2.24, 95% CI: 1.58-3.16).

CONLUSIONS

This cross-national study shows that individuals with VI are at high risk for future CVD.

Evaluating the precision of an online visual acuity test tool

OBJECTIVE

The aim of this study was to assess the precision of a web-based tool in measuring visual acuity (VA) in ophthalmic patients, comparing it to the traditional in-clinic evaluation using a Snellen chart, considered the gold standard.

METHODS

We conducted a prospective and in-clinic validation comparing the Eyecare Visual Acuity Test® to the standard Snellen chart, with patients undergoing both tests sequentially. Patients wore their standard spectacles as needed for both tests. Inclusion criteria involved individuals above 18 years with VA equal to or better than +1 logMar (20/200) in each eye. VA measurements were converted from Snellen to logMAR, and statistical analyses included Bland-Altman and descriptive statistics.

RESULTS

The study, encompassing 322 patients and 644 eyes, compared Eyecare Visual Acuity Test® to conventional methods, revealing a statistically insignificant mean difference (0.01 logMAR, P = 0.1517). Bland-Altman analysis showed a narrow 95% limit of agreement (0.22 to -0.23 logMAR), indicating concordance, supported by a significant Pearson correlation (r = 0.61, P < 0.001) between the two assessments.

CONCLUSION

The Eyecare Visual Acuity Test® demonstrates accuracy and reliability, with the potential to facilitate home monitoring, triage, and remote consultation. In future research, it is important to validate the Eyecare Visual Acuity Test® accuracy across varied age cohorts, including pediatric and geriatric populations, as well as among individuals presenting with specific comorbidities like cataract, uveitis, keratoconus, age-related macular disease, and amblyopia.

First-in-Human Whole-Eye Transplantation: Ensuring an Ethical Approach to Surgical Innovation

As innovations in the field of vascular composite allotransplantation (VCA) progress, whole-eye transplantation (WET) is poised to transition from non-human mammalian models to living human recipients. Present treatment options for vision loss are generally considered suboptimal, and attendant concerns ranging from aesthetics and prosthesis maintenance to social stigma may be mitigated by WET. Potential benefits to WET recipients may also include partial vision restoration, psychosocial benefits related to identity and social integration, improvements in physical comfort and function, and reduced surgical risk associated with a biologic eye compared to a prosthesis. Perioperative and postoperative risks of WET are expected to be comparable to those of facial transplantation (FT), and may be similarly mitigated by immunosuppressive protocols, adequate psychosocial support, and a thorough selection process for both the recipient and donor. To minimize the risks associated with immunosuppressive medications, the first attempts in human recipients will likely be performed in conjunction with a FT. If first-in-human attempts at combined FT-WET prove successful and the biologic eye survives, this opens the door for further advancement in the field of vision restoration by means of a viable surgical option. This analysis integrates recent innovations in WET research with the existing discourse on the ethics of surgical innovation and offers preliminary guidance to VCA programs considering undertaking WET in human recipients.

Simulation of visual impairment in persons with normal vision for scientific research

Simulation of visual impairment in healthy eyes has multiple applications in students' training, research and product development. However, due to the absence of an existing standard protocol, the method of simulation was left to the discretion of the researcher. This review aimed to outline the various methods of simulating visual impairment and categorising them. A scoping review of the relevant publications was conducted. Of the 1593 articles originally retrieved from the databases, 103 were included in the review. The characteristics of the participants, the method for simulation of the visual impairment in persons with normal vision and the level or type of visual impairment that was simulated were extracted from the papers. None of the methods of simulation can be judged as being superior to the others. However, electronic displays produced the most consistent form of visual impairment simulation.

Prevalence of self-reported visual impairment among people in Canada with and without diabetes: findings from population-based surveys from 1994 to 2014

BACKGROUND

Diabetes, a leading cause of visual impairment, is on the rise in Canada. We assessed trends in the prevalence of visual impairment among people in Canada with and without diabetes to inform the development of strategies and policies for the management of visual impairment.

METHODS

We analyzed self-reported data from respondents aged 45 years and older in 7 cycles of nationwide surveys (National Population Health Survey and Canadian Community Health Survey) from 1994/95 to 2013/14. The age- and sex-standardized prevalence of visual impairment was calculated. We assessed comparisons by levels of education and income, using sex-standardized prevalence owing to sparse data.

RESULTS

Among people in Canada with diabetes, the age- and sex-standardized prevalence of visual impairment was 7.37% (95% confidence interval [CI] 5.31%-9.43%) in 1994/95 and 1996/97 combined, decreasing to 3.03% (95% CI 2.48%-3.57%) in 2013/14, giving a standardized prevalence ratio of 0.41 (95% CI 0.30-0.56) comparing 2013/14 with 1994/95 and 1996/97 combined. Among people in Canada without diabetes, visual impairment prevalence decreased from 3.72% (95% CI 3.31%-4.14%) in 1994/95 and 1996/97 combined to 1.69% (95% CI 1.52%-1.87%) in 2013/14, with a standardized prevalence ratio of 0.45 (95% CI 0.40-0.52). Decreased sex-standardized prevalence of visual impairment was observed among people with high and low education levels and incomes among those with and without diabetes.

INTERPRETATION

Visual impairment prevalence was roughly 2 times higher among those with versus without diabetes in all survey years; from 1994 to 2014, visual impairment prevalence decreased among those with and without diabetes irrespective of education and income levels. These results suggest effective collective efforts by clinicians, researchers, the public and government.

Self-reported symptoms of everyday executive dysfunction, daytime sleepiness, and fatigue and health status among adults with congenital aniridia: a descriptive study

Background

Congenital aniridia is a rare genetic disorder of the eye characterized by visual impairment and progressive vision loss. While prior research has focused on ocular manifestations in individuals with aniridia, there is a dearth of research on impacts on cognition and mental health. The aims of this study were to describe subjective symptoms of everyday executive functioning, fatigue and sleepiness in adults with aniridia and to compare self-reported health status with that of a normative reference group.

Methods

Twenty-nine adults (aged 18-79 years) with congenital aniridia were included in this online survey, of whom 52% were females. Participants completed self-report measures of executive functioning (The Behavior Rating Inventory of Executive Function-Adult Version), sleepiness, fatigue, and health status (EQ-5D-5L).

Results

Participants reported relatively few problems in everyday executive functioning, with only 14% experiencing impaired executive functioning. Scores on the five EQ-5D-5L domains (mobility, self-care, usual activities, pain, and anxiety/depression) did not differ from those of the normative reference group. The frequencies of excessive daytime sleepiness and severe fatigue were 17% and 38%, respectively. Ocular pain was experienced by 62% of participants.

Conclusions

The findings show that cognitive problems are related to and reflect self-reported health status and extent of fatigue. Moreover, those who suffered from ocular pain reported more difficulties with executive functioning, sleepiness and fatigue. These findings are important for understanding this disorder and supporting patients.

Screening for Patients with Visual Acuity Loss in Primary Health Care: A Cross Sectional Study in a Deprived Hungarian Population

Screening for visual acuity loss (VAL) is not applied systematically because of uncertain recommendations based on observations from affordable countries. Our study aimed to evaluate the effectiveness of primary health care-based screening. A cross-sectional investigation was carried out among adults who did not wear glasses and did not visit an ophthalmologist in a year (N = 2070). The risk factor role of sociodemographic factors and the cardiometabolic status for hidden VAL was determined by multivariable linear regression models. The prevalence of unknown VAL of at least 0.5 was 3.7% and 9.1% in adults and in the above-65 population. Female sex (b = 1.27, 95% CI: 0.35; 2.18), age (b = 0.15, 0.12; 0.19), and Roma ethnicity (b = 2.60, 95% CI: 1.22; 3.97) were significant risk factors. Higher than primary school (b_{secondaryschoolwithoutgraduation} = -2.06, 95% CI: -3.64; -0.47; and b_{secondaryschoolwithgraduation} = -2.08, 95% CI: -3.65; -0.51), employment (b = -1.33, 95% CI: -2.25; 0.40), and properly treated diabetes mellitus (b = -2.84, 95% CI: -5.08; -0.60) were protective factors. Above 65 years, female sex (b = 3.85, 95% CI: 0.50; 7.20), age (b = 0.39, 95% CI: 0.10; 0.67), Roma ethnicity (b = 24.79, 95% CI: 13.83; 35.76), and untreated diabetes (b = 7.30, 95% CI: 1.29; 13.31) were associated with VAL. Considering the huge differences between the health care and the population's social status of the recommendation-establishing countries and Hungary which represent non-high-income countries, the uncertain recommendation of VAL screening should not discourage general practitioners from organizing population-based screening for VAL in non-affordable populations.

A scoping review of patients' barriers to eye care for glaucoma and keratitis

In this scoping review, we examine underlying causes of loss to follow-up for chronic (glaucoma) and acute (corneal ulcers) eye conditions using the Penchansky and Thomas access to care framework. We explore barriers by World Health Organization income levels and by studying geographical location. We identified 6,363 abstracts, with 75 articles retrieved and 16 meeting inclusion criteria. One article discussed barriers to follow-up care for people with corneal ulcers, and the other 15 were for people with glaucoma. The most frequent barriers to care were affordability, awareness, and accessibility. The international studies had a greater percentage of studies report acceptability as a barrier to loss to follow-up. Countries with universal healthcare included affordability as a loss to follow-up barrier, emphasizing that cost goes beyond the ability to pay for direct treatment costs. Understanding and addressing barriers to follow-up care can aid the goal of continued care and decrease the risk of poor outcomes and vision loss.

Potential Properties of Natural Nutraceuticals and Antioxidants in Age-Related Eye Disorders

Eye health is crucial, and the onset of diseases can reduce vision and affect the quality of life of patients. The main causes of progressive and irreversible vision loss include various pathologies, such as cataracts, ocular atrophy, corneal opacity, age-related macular degeneration, uncorrected refractive error, posterior capsular opacification, uveitis, glaucoma, diabetic retinopathy, retinal detachment, undetermined disease and other disorders involving oxidative stress and inflammation. The eyes are constantly exposed to the external environment and, for this reason, must be protected from damage from the outside. Many drugs, including cortisonics and antinflammatory drugs have widely been used to counteract eye disorders. However, recent advances have been obtained via supplementation with natural antioxidants and nutraceuticals for patients. In particular, evidence has accumulated that polyphenols (mostly deriving from Citrus Bergamia) represent a reliable source of antioxidants able to counteract oxidative stress accompanying early stages of eye diseases. Luteolin in particular has been found to protect photoreceptors, thereby improving vision in many disease states. Moreover, a consistent anti-inflammatory response was found to occur when curcumin is used alone or in combination with other nutraceuticals. Additionally, Coenzyme Q10 has been demonstrated to produce a consistent effect in reducing ocular pressure, thereby leading to protection in patients undergoing glaucoma. Finally, both grape seed extract, rich in anthocyanosides, and polynsatured fatty acids seem to contribute to the prevention of retinal disorders. Thus, a combination of nutraceuticals and antioxidants may represent the right solution for a multi-action activity in eye protection, in association with current drug therapies, and this will be of potential interest in early stages of eye disorders.

The impact of COVID-19 on the everyday life of blind and sighted individuals

The COVID-19 pandemic caused unexpected and unavoidable changes in daily life worldwide. Governments and communities found ways to mitigate the impact of these changes, but many solutions were inaccessible to people with visual impairments. This work aimed to investigate how blind individuals subjectively experienced the restrictions and isolation caused by the COVID-19 pandemic. To this end, a group of twenty-seven blind and seventeen sighted people took part in a survey addressing how COVID-19 impacted life practically and psychologically, how it affected their daily habits, and how it changed their experiences of themselves and others. Results demonstrated that both sighted and blind individuals had a hard time adapting to the new situation. However, while sighted people struggled more with personal and social aspects, the frustration of the blind population derived mostly from more practical and logistical issues. Likely as consequences, results showed that blind people engaged more in their inner life and experienced fear and anger as main emotions. This study suggests that changes in life associated with COVID-19 have been subjectively experienced differently based on the presence or not of blindness, and that tailored future interventions should be considered to take care of the different needs of blind individuals.

"To Be Treated as a Person and Not as a Disease Entity"-Expectations of People with Visual Impairments towards Primary Healthcare: Results of the Mixed-Method Survey in Poland

Primary care is the core part of the Polish healthcare system. Improving its quality for vulnerable populations is among the principal goals of global and national health policies. Identifying patients' needs is critical in this process. People who are blind or have low vision often demonstrate comorbidities and require more specific healthcare. The aim of this study was to explore the needs of Polish persons with visual impairments when they use primary care services. 219 respondents answered the "Patient value" questionnaire from the project Quality and Costs of Primary Care in Europe (QUALICOPC) and an open question regarding additional patients' needs. Statistical and content analyses were used. The expectations of the study group regarding primary care appeared to be higher than those described in studies among other populations. Equity and accessibility were the most valued dimensions of care. Among particular aspects of care, those connected with psychosocial competencies and awareness of disability among medical staff appeared most frequently. Some personal characteristics were associated with preferences, including age, gender, longstanding conditions, quality of life, and disability-related variables. Our study indicates a need for multilevel interventions in legislation, economics, and medical staff training, with the people-centered approach as the option maximizing chances to meet diverse healthcare needs arising from particular disabilities.

Predictors of problems reported on the EQ-5D-3L dimensions among people with impaired vision in northern Portugal

BACKGROUND

The EQ-5D index often fails to detect the effect of ophthalmic diseases and sight loss. Investigating predictors of individual EQ-5D health dimensions might reveal the underlying reasons. The aim of this study was to investigate predictors of health dimension ratings obtained with the EQ-5D-3L from participants with impaired vision representing a spectrum of eye diseases.

METHODS

Observational cross-sectional study with participants recruited at four public hospitals in Portugal. Outpatients with visual acuity of 0.30 logMAR(6/12) or worse in the better-seeing eye were invited to participate. Participants completed two instruments: the EQ-5D-3L (measures participants' perceived health-related quality-of-life) and the Massof Activity Inventory (measures visual ability-ability to perform vision-related activities). This study used logistic regression models to identify factors associated with responses to the EQ-5D-3L.

RESULTS

The study included 492 participants, mean age 63.4 years (range = 18-93), 50% females. The most common diagnosis was diabetic retinopathy (37%). The mean visual acuity in the better seeing eye was 0.65 logMAR (SD = 0.48) and the mean visual ability was 0.62 logits (SD = 2.04), the correlation between the two was r = - 0.511 (p < 0.001). Mobility and self-care were the health dimensions with the fewest problems (1% reported extreme problems), anxiety and depression the dimension with the most problems (24% reported extreme problems). ROC curve analysis showed that the EQ-5D index was a poor predictor of cases of vision impairment whilst visual ability given was a good predictor of cases of vision impairment. Visual ability was an independent predictor of the response for all dimensions, higher ability was always associated with a reduced odds of reporting problems. The odds of reporting problems were increased for females in 3 out of 5 dimensions. Comorbidities, visual acuity and age-category were predictors of the odds of reporting problems for one dimension each.

CONCLUSIONS

The odds of reporting problems for the five health dimensions of the EQ-5D-3L were strongly influenced by the ability to perform vision-related activities (visual ability). The EQ-5D index showed poor performance at detecting vision impairment. These findings are informative and relevant for the clinic and for research evaluating the impact of eye diseases and disease treatments in ophthalmology.

Anxiety levels moderate the association between visual acuity and health-related quality of life in chronic eye disease patients

The current study examines the potential moderating effect of depression and anxiety on the relationship between visual acuity and health-related quality of life in patients with chronic eye diseases. Of the 71 patients, 37 (52%) were female and 34 (48%) were male, age (mean ± SD) was 69 ± 12 years. A significant multivariate regression model was found for patients' health-related quality of life (EQ-5D-5L index) (R² = 0.43, p < 0.001), in which visual acuity (logMAR) (p < 0.001), anxiety (HADS-A) (p = 0.007), and age of diagnosis (p = 0.04)  were independently associated with health-related quality of life (EQ-5D-5L). The moderation model for anxiety (R² = 0.47, F = 5.91, p < 0.001) revealed a significant interaction of visual acuity and levels of anxiety in relation to health-related quality of life. Conditional effects analysis suggested that higher logMAR values (which indicate more vision loss) were associated with lower EQ-5D-5L index (indicating worse health-related quality of life), this relationship being stronger (even more negative), when levels of anxiety are high. Clinical and rehabilitation services providing care for chronic eye disease patients should include regular checks for patients' levels of anxiety, even in patients who still have preserved visual acuity, to help preventing a synergistic source of long-term poor quality of life and disability.

Association between Vision Impairment and Physical Quality of Life Assessed Using National Surveillance Data

SIGNIFICANCE

Physically unhealthy days assessments in national health surveillance datasets represent a useful metric for quantifying quality-of-life differences in those with and without vision impairment. Disproportionately poorer physical health in the visually impaired population provides further rationale for the inclusion of vision care in multidisciplinary approaches to chronic disease management.

PURPOSE

This study aimed to assess the association between vision impairment and health-related quality of life using data from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System.

METHODS

Data from each of the 50 states were extracted from the 2017 Behavioral Risk Factor Surveillance System data set. Self-report of difficulty seeing was used to categorize visually impaired versus nonvisually impaired populations. Self-report number of physically unhealthy days in the previous 30 days was used to quantify quality of life. The number of unhealthy days was calculated for the visually impaired and nonvisually impaired cohorts for each state. The ratio of the number of physically unhealthy days in the visually impaired versus nonvisually impaired population was calculated for each state and for different age cohorts.

RESULTS

Mean numbers of physically unhealthy days among persons with and without severe vision impairment across all states were 10.63 and 3.68 days, respectively, and demonstrated considerable geographic variability. Mean ratios of physically unhealthy healthy days in the visually impaired versus the nonvisually impaired population were 2.91 in the 18- to 39-year-old cohort, 2.87 in the 40- to 64-year-old cohort, and 2.16 in the ≥65-year-old cohort.

CONCLUSIONS

National surveillance data demonstrate a greater number of physically unhealthy days in the visually impaired population, indicating a need to improve our understanding of causes that lead to reduced physical health among those with vision impairment. Additional research is needed to better understand how individuals perceive vision as part of their overall health.

Improvement in general health after cataract surgery is not limited to vision-specific function

Cataract surgery is known to have a beneficial impact on quality of life. Recent studies claimed that disease-specific measures of functional impairment are more sensitive to preoperative functional impairment and gains from surgery than are generic measures of general health and quality of life. The purpose of this study is to ascertain whether measures of general health provide additional information on the improvement of patients following cataract surgery over measures of visual function. This is an observational prospective study of a cohort of 150 consecutive patients who underwent phacoemulsification surgery and were evaluated for changes in health-related quality of life with the Medical Outcomes Study Short-Form 36 (SF-36) and improvement in visual-related functioning with the 14-item Visual Function test (VF-14). All of the SF-36 subscales improved post operatively with the magnitude of improvement in VF-14 significantly affecting all subscales except for the Vitality subscale. Treatment effects were significant for the SF-36 subscales 'Role limitations due to physical health', 'Role limitations due to emotional problems', 'Social Functioning' and 'General Health', while taking into account the difference in VF-14 scores pre and postoperatively (p < 0.001). The outcome of phacoemulsification surgery for cataract cannot be completely ascertained solely by the measurement of improvement on tasks related to visual functioning, leaving unaccounted a component related to self-appraisal of ability in everyday and social function, as well as the general feeling of subjective health. The concurrent use of general health measures with visual functioning measures to account for the general improvement on health status following cataract surgery is thus justified.

Racial/ethnic differences in health-related quality of life among Hawaii adult population

Background

This study examined racial/ethnic differences in health-related quality of life (HRQOL) among adults and identified variables associated with HRQOL by race/ethnicity.

Methods

This study was conducted under a cross-sectional design. We used the 2011–2016 Hawaii Behavioral Risk Factor Surveillance System data. HRQOL were assessed by four measures: self-rated general health, physically unhealthy days, mentally unhealthy days, and days with activity limitation. Distress was defined as fair/poor for general health and 14 days or more for each of the other three HRQOL measures. We conducted multivariable logistic regressions with variables guided by Anderson’s behavioral model on each distress measure by race/ethnicity.

Results

Among Hawaii adults, 30.4% were White, 20.9% Japanese, 16.8% Filipino, 14.6% Native Hawaiian and Pacific Islander (NHPI), 5.9% Chinese, 5.2% Hispanics, and 6.2% Other. We found significant racial/ethnic differences in the HRQOL measures. Compared to Whites, Filipinos, Japanese, NHPIs, and Hispanics showed higher distress rates in general health, while Filipinos and Japanese showed lower distress rates in the other HRQOL measures. Although no variables were consistently associated with all four HRQOL measures across all racial/ethnic groups, history of diabetes were significantly associated with general health across all racial/ethnic groups and history of depression was associated with at least three of the HRQOL measure across all racial/ethnic groups.

Conclusions

This study contributes to the literature on disparities in HRQOL and its association with other variables among diverse racial/ethnic subgroups. Knowing the common factors for HRQOL across different racial/ethnic groups and factors specific to different racial/ethnic groups will provide valuable information for identifying future public health priorities to improve quality of life and reduce health disparities.

Impact of the affordable care act on utilization of benefits of eye care and primary care examinations

Purpose

To determine the impact of the Affordable Care Act (ACA) on utilization of benefits of both eye care and primary care examinations in individuals who did not have health insurance prior to the ACA.

Methods

Patients examined in an urban eye clinic from 2017 to 2018 were invited to participate. Patients were classified into two groups: Insured Group, who had health insurance before and after the ACA; The ACA Group, who had insurance only after the ACA. Patients were surveyed on how often they were examined by their eye care and primary care physicians before and after the ACA. The care utilization frequency was categorized into 3 levels: Frequent Care Use, Rare Care Use, and Never. To test the utilization of benefits frequency difference between two groups, the z-ratio was calculated.

Results

A total of 4,355 patients were enrolled with 87.1% in the Insured Group and 12.9% in the ACA Group. After the ACA implementation, the percentage of “Frequent Care Use” of the eye care and primary care in the ACA Group patients significantly increased from 31.2% and 53.7% to 57.9% and 74.9%, respectively (P<0.001), but were significantly lower than those in the Insured Group (76.6% and 93.9%, P < 0.001).

Conclusion

The ACA significantly improved utilization of benefits of eye care and primary care for individuals in the ACA Group. Although improved, those patients who received health insurance through the ACA still had lower utilization of benefits than those in the Insured Group.

Eye health and quality of life: an umbrella review protocol

INTRODUCTION

Vision impairment and eye disease are major global health concerns and have been associated with increased morbidity and mortality, and lower quality of life. Quality of life, whether generic, vision-specific or disease-specific, is an important measure of the impact of eye health on people's daily activities, well-being and visual function, and is increasingly used to evaluate the impact of ophthalmic interventions and new devices. While many studies and reviews have examined the relationship between vision or eye health and quality of life across different contexts, there has yet to be a synthesis of the impact of vision impairment, eye disease and ophthalmic interventions on quality of life globally and across the lifespan.

METHODS AND ANALYSIS

An umbrella review of systematic reviews will be conducted to address these two questions: (1) What is the association of vision impairment and eye disease with quality of life? (2) What is the impact of ophthalmic interventions on quality of life? A search of related literature will be performed on the 11 February 2020 in Medline Ovid, Embase.com, Cochrane Database of Systematic Reviews, Proquest Dissertations and Theses Global, and the grey literature, and repeated at the synthesis stage. Title/abstract and full-text screening, methodological quality assessment and data extraction will be conducted by reviewers working independently and in duplicate. Assessment of methodological quality and data extraction will be performed using Joanna Briggs Institute standard forms. Findings from the systematic reviews and their methodological quality will be summarised qualitatively in the text and using tables.

ETHICS AND DISSEMINATION

No ethical approval is required. Results of this umbrella review will be published in a peer-reviewed journal and summarised in the Lancet Global Health Commission on Global Eye Health.

TRIAL REGISTRATION NUMBER

This protocol was registered in the Open Science Framework Registries (https://osf.io/qhv9g/).

Influence of Distance and Near Visual Impairment on Self-Reported Near Visual Functioning in a Multinational Study

PURPOSE

To assess the influence of distance and near visual impairment on self-reported near visual functioning (VF) in a multinational study.

DESIGN

Population-based cross-sectional study.

PARTICIPANTS

Participants aged 35 years or older were selected randomly with cluster sampling at 7 sites: rural sites in Nepal (Kaski) and India (Madurai), a semirural site in China (Shunyi), semiurban sites in South Africa (Durban) and Niger (Dosso), and urban sites in the United States (Los Angeles) and China (Guangzhou).

METHODS

Binocular presenting distance and near visual acuity (VA) were measured with a logarithm of the minimum angle of resolution tumbling E chart at 4 m and 40 cm, respectively. A 12-item near VF questionnaire interview was administered by trained local interviewers, with responses scored from 100 to 0 as visual disability increased. Multiple linear regression was used to investigate the association of age, gender, education, and VA with overall eyesight, difficulty with activities, and social functioning subscale scores.

MAIN OUTCOME MEASURES

Visual functioning subscale scores.

RESULTS

The study sample consisted of 6851 questionnaire respondents. The VF subscale scores decreased significantly with worse distance and near VA, and even mildly impaired VA could result in reduced VF. Lower VF subscale scores were associated with older age at 4 sites, female gender at 3 sites, and greater education at 2 sites. The influence of near VA was greater than distance VA at 3 sites, and at 1 site, distance VA was more influential than near VA. With study site included in the regression modeling, lower scores for the overall eyesight subscale (compared with the Shunyi reference site) were found in Guangzhou, Kaski, and Durban; lower difficulty in activities scores were found in Kaski and Durban, but better scores were found in Guangzhou and Madurai; and social functioning scores were lower in Kaski, Durban, and Dosso.

CONCLUSIONS

Along the entire VA spectrum, lower levels of distance and near VA led to significant reductions in VF subscale scores, with wide variation both within and between study sites. The impact of near vision on VF should receive greater emphasis with further investigation in various socioeconomic and cultural settings.

Associations between adult attachment and vision-related quality of life in visually impaired individuals

PURPOSE

An attachment theory framework approach may allow insight into how social and psychosocial factors interact to impact vision-related quality of life (QoL). In this pilot study, we investigated potential associations between adult attachment style and visual function QoL of visually impaired individuals.

METHODS

We recruited 38 visually impaired individuals (15 females, 23 males; 51.8 ± 16.0 years). Visual function measures included distance and near visual acuity (VA) and contrast sensitivity. All participants completed: the 25-item National Eye Institute Visual Functioning Questionnaire-25 (NEI-VFQ 25) and the Experiences in Close Relationships-Relationships Structures questionnaire.

RESULTS

Presenting conditions included inherited retinal dystrophy (n = 10), nystagmus (n = 9), glaucoma (n = 7) and other eye conditions (n = 12). There was a statistically significant negative correlation between the NEI-VFQ-25 composite score (45.5 ± 14.7) and attachment-related anxiety (r = -0.352, p = 0.033). The latter correlation still held when controlling for participants' level of vision (r = -0.352, p = 0.035). Despite the range of conditions and wide age range, these were not significantly correlated with any variable of interest in the current study.

CONCLUSION

Attachment-related anxiety ought to be taken into account when managing a visually impaired individual. Attachment-based approaches could be used to improve access to support services for visually impaired individuals, as well as self-management of their condition.

Eye Care Among US Adults at High Risk for Vision Loss in the United States in 2002 and 2017

Importance

Timely eye care can prevent unnecessary vision loss.

Objectives

To estimate the number of US adults 18 years or older at high risk for vision loss in 2017 and to evaluate use of eye care services in 2017 compared with 2002.

Design, Setting, and Participants

This survey study used data from the 2002 (n = 30 920) and 2017 (n = 32 886) National Health Interview Survey, an annual, cross-sectional, nationally representative sample of US noninstitutionalized civilians. Analysis excluded respondents younger than 18 years and those who were blind or unable to see. Covariates included age, sex, race/ethnicity, marital status, educational level, income-to-poverty ratio, health insurance status, diabetes diagnosis, vision or eye problems, and US region of residence.

Main Outcomes and Measures

Three self-reported measures were visiting an eye care professional in the past 12 months, receiving a dilated eye examination in the past 12 months, and needing but being unable to afford eyeglasses in the past 12 months. Adults at high risk for vision loss included those who were 65 years or older, self-reported a diabetes diagnosis, or had vision or eye problems. Multivariable logistic regression models incorporating sampling weights were used to investigate associations between measures and covariates. Temporal comparisons between 2002 and 2017 were derived from estimates standardized to the US 2010 census population.

Results

Among 30 920 individuals in 2002, 16.0% were 65 years or older, and 52.0% were female; among 32 886 individuals in 2017, 20.0% were 65 years or older, and 51.8% were female. In 2017, more than 93 million US adults (37.9%; 95% CI, 37.0%-38.7%) were at high risk for vision loss compared with almost 65 million (31.5%; 95% CI, 30.7%-32.3%) in 2002, a difference of 6.4 (95% CI, 5.2-7.6) percentage points. Use of eye care services improved (56.9% [95% CI, 55.7%-58.7%] reported visiting an eye care professional annually, and 59.8% [95% CI, 58.6%-61.0%] reported receiving a dilated eye examination), but 8.7% (95% CI, 8.0%-9.5%) said they could not afford eyeglasses (compared with 51.1% [95% CI, 49.9%-52.3%], 52.4% [95% CI, 51.2%-53.6%], and 8.3% [95% CI, 7.7%-8.9%], respectively, in 2002). In 2017, individuals with lower income compared with high income were more likely to report eyeglasses as unaffordable (13.6% [95% CI, 11.6%-15.9%] compared with 5.7% [95% CI, 4.9%-6.6%]).

Conclusions and Relevance

Compared with data from 2002, more US adults were at high risk for vision loss in 2017. Although more adults used eye care, a larger proportion reported eyeglasses as unaffordable. Focusing resources on populations at high risk for vision loss, increasing awareness of the importance of eye care, and making eyeglasses more affordable could promote eye health, preserve vision, and reduce disparities.

Self-Reported Oral Health Status Among Adults Aged 40+ Years With and Without Vision Impairment: National Health Interview Study, 2008

PURPOSE

To examine self-reported oral health among adults aged 40 years and older with and without vision impairment.

DESIGN

Cross-sectional, with a nationally representative sample.

METHODS

We used publicly available data from the Oral Health Module, last administered in 2008, of the National Health Interview Survey. Outcome variables included fair/poor oral health status, mouth condition compared to others the same age, mouth problems (mouth sores, difficulty eating, dry mouth, bad breath, and/or jaw pain), teeth problems (toothache; broken/missing fillings or teeth; loose, crooked, or stained teeth; and/or bleeding gums), and lack of social participation. Using descriptive statistics and multivariate logistic regression, we examined the association (P < .05) between vision impairment and oral health outcomes by age group, sociodemographics, and other explanatory variables.

RESULTS

Our study sample included 12,090 adults; 12.8% of adults aged 40-64 years reported vision impairment, and among them, 44.5% reported fair/poor oral health status and 47.2% reported any mouth problems. Among adults aged ≥65 years, 17.3% reported vision impairment, of whom 36.3% reported fair/poor oral health status and 57.3% reported any mouth problems. There is a strong association between vision impairment and poorer oral health of adults; adults aged 40-64 years with vision impairment reported 90%-150% greater odds of oral health problems, including fair/poor oral health status, mouth problems, and teeth problems, compared to people without vision impairment.

CONCLUSIONS

Oral health disparities exist between adults with and without vision impairment. Targeted interventions are required to improve oral health in this vulnerable population.

Barriers to eye care among participants of a mobile eye clinic

Purpose

Barriers to health care present complex challenges to improving eye health in the U.S., yet few studies have quantitatively measured the impact of these barriers. This study investigated the time elapsed since a person's most recent eye examination (TLEE) as a measure of barriers to eye care.

Methods

Participants (N=1699) from mobile clinic vision health screenings completed demographic and subjective visual function questionnaires, and then underwent comprehensive eye exams. Associations between demographics, subjective visual function, and visual acuity were analyzed with respect to TLEE.

Results

Many Hispanic (34.9%) and uninsured (28.6%) participants had no previous eye exam. Although most Caucasians had a previous eye exam, 40.2% did not have an exam in the previous four years. The majority of participants with diabetes were non-compliant with recommendations of annual eye examinations.

Conclusion

These results describe barriers that are specific to subpopulations, providing useful information for efforts to improve eye care access.

Blindness and Visual Impairment in the Medicare Population: Disparities and Association with Hip Fracture and Neuropsychiatric Outcomes

Purpose: Vision loss has been associated with negative health outcomes, but population-level data on vision loss are lacking, and there are limited data on low vision-associated outcomes among women, minorities, and older age groups. The objective of this study was to determine the prevalence of vision loss in a nationally representative sample of older US adults and examine its association with hip fracture, depression, anxiety, and dementia. Methods: Cross-sectional analysis of Medicare claims data from 2014. Blindness and low vision, hip fracture, depression, anxiety, and dementia were identified using Chronic Condition Warehouse indicator variables based on ICD-9 and CPT codes. Multivariable logistic regression models were built to examine whether sociodemographic factors were associated with vision loss and to determine the relationships between vision loss and hip fracture and neuropsychiatric outcomes. Results: The prevalence of low vision in the Medicare population was 994/100,000 and increased significantly with age, Black (1,854/100,000) or Hispanic (2,862/100,000) race/ethnicity, female gender (1,181/100,000), and Medicaid eligibility (2,975/100,000). After adjusting for relevant comorbidities, low vision was significantly associated with hip fracture (adjusted odds ratio [AOR] 2.54, 95% CI: 2.52-2.57), depression (AOR 3.99, 95% CI: 3.97-4.01), anxiety (AOR 2.93, 95% CI: 2.91-2.95), and dementia (AOR 3.91, 95% CI: 3.88-3.93). Conclusion: Blindness and low vision are common in older Americans, especially among racial and ethnic minorities and lower income individuals, and associated with hip fracture, depression, anxiety, and dementia. The prevention and treatment of vision loss may reduce health disparities and negative health outcomes in the aging population.

Loneliness among adults with visual impairment: prevalence, associated factors, and relationship to life satisfaction

Background

Little is known about whether and to what extent loneliness impacts the lives of people with visual impairment (VI). Thus, the aim of this study was to examine the prevalence of and factors associated with loneliness in adults with VI, and to examine its association with life satisfaction.

Methods

This cross-sectional interview study included a probability sample of 736 adults (≥18 years old) with VI who were members of the Norwegian Association of the Blind and Partially Sighted. The interviews took place from January to May 2017, collecting information about sociodemographics, VI characteristics, adverse life events, loneliness (Three Item Loneliness Scale), and life satisfaction (Cantril’s Ladder of Life Satisfaction). The prevalence of loneliness was compared to data obtained from the general Norwegian population (N = 14,884; mean age 46.4 years; 50.7% females).

Results

The prevalence of moderate and severe loneliness in the VI population was 28.7% (95% CI: 25.4, 32.1) and 19.7% (95% CI: 16.9, 22.8), respectively. The rates were consistently higher across age groups compared to the general population. Loneliness was associated with younger age, blindness, having other impairments, unemployment, and a history of bullying or abuse. In addition, higher scores on loneliness were associated with lower levels of life satisfaction (fully adjusted β = − 0.48, 95% CI: − 0.55, − 0.41).

Conclusions

Loneliness is common in adults with VI. Strategies capable of reducing loneliness could improve life satisfaction among people who are blind or visually impaired.

Electronic supplementary material

The online version of this article (10.1186/s12955-019-1096-y) contains supplementary material, which is available to authorized users.

Incidence and risk of major heart diseases in middle-aged adults with moderate to severe vision impairment: a population-based cohort study

BACKGROUND/AIM

To estimate the incidence and risk of major adverse cardiovascular events (MACEs), including heart failure and ischaemic heart disease, among middle-aged people with a visual disability (VD).

METHODS

We used a national health insurance research database to conduct a population-based cohort study from 1 January 2000 to 31 December 2013. Patients with VD aged 35~65 years were recruited. For each VD patient, five age-matched, sex-matched and comorbidity-matched patients were randomly selected and recruited as controls. Control patients had no documented disability.

RESULTS

This study recruited 978 patients with VD (mean age±SD, 55.1±7.8 years; 48.9% male) and 4677 controls. Compared with the same sex of the controls, women with VD had higher incidence of MACE 1 (7.9 vs 2.8/1000 person-years, p<0.001), MACE 2 (27.5 vs 16.9/1000 person-years, p<0.001), MACE 3 (3.7 vs 1.4/1000 person-years, p<0.005) and MACE 4 (4.5 vs 2.5/1000 person-years, p<0.05), and men with VD had higher incidence of MACE 1 (4.6 vs 2.0/1000 person-years, p<0.005). Compared with the controls, patients with VD had lower cumulative MACE 1~MACE 4-free probabilities and had an independently higher risk of MACE 1~MACE 4 during the 13-year study, yielding an adjusted hazard ratio range of 1.31~2.75. Those persons with VD who had diabetes and hypertension had greater risks of MACE 1~MACE 4.

CONCLUSIONS

Middle-aged adults with VD were at risk of MACEs. A programme for MACE prevention is important for middle-aged people with VD. This is especially true for women and for those who also have diabetes and hypertension.

Visual, musculoskeletal and balance symptoms in individuals with visual impairment

BACKGROUND

Visual impairment is globally among the most prevalent disabilities. Research concerning the health consequences of visual deficits is challenged by confounding effects of age, because visual impairment becomes more prevalent with age. This study investigates the influence of visual deficits on visual, musculoskeletal and balance symptoms in adults with and without visual impairment, while controlling for age effects.

METHODS

Thirty-nine patients with visual impairment, aged 18-72 years, were compared to 37 age-matched controls with normal vision, allocated to two age groups: < 45 and ≥ 45 years. Self-reported symptoms were measured using the Visual, Musculoskeletal and Balance Symptoms Questionnaire and compared with demographic and optometric variables.

RESULTS

In total, patients with visual impairment reported more symptoms than age-matched normally sighted controls. Younger adults in the control group were almost free from symptoms, whereas younger adults with visual impairment reported levels of symptoms equal to older adults with visual impairment. Multiple logistic regression modelling identified use of eyeglasses, magnifying aids and presence of anisometropia to be the most influential risk factors for reporting visual, musculoskeletal and balance symptoms, with accentuated influence on balance symptoms.

CONCLUSIONS

People with visual impairments and people with age-related normal visual deficits are both predisposed to report visual, musculoskeletal and balance symptoms relative to people without visual defects or need for eye-wear correction. Age-related variations in symptoms were observed in the control groups but not in the visual impairment groups, with younger visual impairment patients reporting as many symptoms as older visual impairment patients. These findings indicate a need for a wider interdisciplinary perspective on eye care concerning people with visual impairment and people with need for habitual daily use of eye wear correction.

The Burden of Stigma on Health and Well-Being: A Taxonomy of Concealment, Course, Disruptiveness, Aesthetics, Origin, and Peril Across 93 Stigmas

Most individuals are stigmatized at some point. However, research often examines stigmas separately, thus underestimating the overall impact of stigma and precluding comparisons across stigmatized identities and conditions. In their classic text, Social Stigma: The Psychology of Marked Relationships, Edward Jones and colleagues laid the groundwork for unifying the study of different stigmas by considering the shared dimensional features of stigmas: aesthetics, concealability, course, disruptiveness, origin, peril. Despite the prominence of this framework, no study has documented the extent to which stigmas differ along these dimensions, and the implications of this variation for health and well-being. We reinvigorated this framework to spur a comprehensive account of stigma's impact by classifying 93 stigmas along these dimensions. With the input of expert and general public raters, we then located these stigmas in a six-dimensional space and created discrete clusters organized around these dimensions. Next, we linked this taxonomy to health and stigma-related mechanisms. This quantitative taxonomy offers parsimonious insights into the relationship among the numerous qualities of numerous stigmas and health.

Self-reported visual impairment, physical activity and all-cause mortality: The HUNT Study

AIMS

To examine the associations of self-reported visual impairment and physical activity (PA) with all-cause mortality.

METHODS

This prospective cohort study included 65,236 Norwegians aged ⩾20 years who had participated in the Nord-Trøndelag Health Study (HUNT2, 1995-1997). Of these participants, 11,074 (17.0%) had self-reported visual impairment (SRVI). The participants' data were linked to Norway's Cause of Death Registry and followed throughout 2012. Hazard ratios and 95% confidence intervals (CI) were assessed using Cox regression analyses with age as the time-scale. The Cox models were fitted for restricted age groups (<60, 60-84, ⩾85 years).

RESULTS

After a mean follow-up of 14.5 years, 13,549 deaths were identified. Compared with adults with self-reported no visual impairment, the multivariable hazard ratios among adults with SRVI were 2.47 (95% CI 1.94-3.13) in those aged <60 years, 1.22 (95% CI 1.13-1.33) in those aged 60-84 years and 1.05 (95% CI 0.96-1.15) in those aged ⩾85 years. The strength of the associations remained similar or stronger after additionally controlling for PA. When examining the joint associations, the all-cause mortality risk of SRVI was higher for those who reported no PA than for those who reported weekly hours of PA. We found a large, positive departure from additivity in adults aged <60 years, whereas the departure from additivity was small for the other age groups.

CONCLUSIONS

Adults with SRVI reporting no PA were associated with an increased all-cause mortality risk. The associations attenuated with age.