Kay Scilley

Early age-related maculopathy and self-reported visual difficulty in daily life

PURPOSE To determine whether early age-related maculopathy (ARM) is associated with visual difficulty in daily activities beyond the difficulty that would be expected based on normal retinal aging; to determine whether scotopic sensitivity and visual acuity are associated with visual difficulties in these older adults. STUDY DESIGN Comparative, cross-sectional questionnaire study. SUBJECTS Ninety-two older adults with early ARM in at least one eye as defined by one or more large (>63 microm) drusen and/or focal hyperpigmentation but no choroidal neovascularization or geographic atrophy, acuity of 20/60 or better, and a reference group of 55 older adults in the same age range without these fundus features and acuity of 20/35 or better in each eye. METHOD Tests of visual acuity and scotopic sensitivity and a general health questionnaire were carried out. The Activities of Daily Vision Scale (ADVS) was administered to assess self-reported visual difficulties in everyday tasks and expressed on a scale of 0 (extreme difficulty) to 100 (no difficulty). Fundus photographs were taken and graded to characterize the presence and severity of ARM to determine eligibility. RESULTS For purposes of analysis, the early ARM group was divided into those whose fellow eye (FE) was 20/60 or better and those whose FE was worse than 20/60. ADVS subscale scores were substantially lower in the early ARM group with FE worse than 20/60 (medians, 58-83) compared with the normal retinal health group (medians, 97-100). Even for those with early ARM with FE 20/60 or better, four of five subscale scores were lower (medians, 81-97), albeit slightly in some cases, than those of the reference group. For both ARM subgroups, the night driving subscale had the lowest scores of all subscales. Persons with early ARM with FE 20/60 or better were more likely to report difficulty on the night driving (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.6-11.4), near vision (OR, 5.0; 95% CI, 1.9-12.9), and glare disability (OR, 2.7; 95% CI, 1.1-6.3) subscales compared with those in normal retinal health, adjusting for age, gender, medical comorbidities, and lens density. For early ARM patients with FE worse than 20/60, there was widespread reporting of difficulty on all subscales (ORs ranging from 4.7-52.9). Poor scotopic sensitivity was highly associated with difficulty on the night driving subscale (OR, 6.6; 95% CI, 1.2-35.5) but not with any other subscale. Acuity worse than 20/25 in both eyes was significantly associated with difficulty on all ADVS subscales; when this acuity impairment was present in one eye only, associations were still significantly present on some subscales, although they were weaker. CONCLUSIONS Persons in the early phases of ARM, even when their fellow eye has relatively good acuity, are more likely to experience difficulty in night driving, near vision tasks, and glare disability compared with those in good retinal health. Scotopic dysfunction, a functional marker of early ARM, is linked to reported night driving problems. Even when acuity impairment occurs in one eye only, patients report difficulties with day driving and near and far vision tasks.

Driving Habits and health-related quality of life in patients with age-related maculopathy

Purpose. To characterize the driving habits of persons with age-related maculopathy who present to a low-vision rehabilitation clinic and to examine how driving status relates to vision-specific health-related quality of life. Methods. The Driving Habits Questionnaire, the National Eye Institute Vision Function Questionnaire-25, and the Life Space Questionnaire were administered via telephone interview to 126 patients with age-related maculopathy who presented to a low-vision clinic during the previous year and were either past or current drivers. Results. Twenty-four percent of the sample reported being a current driver. Compared with those who stopped driving, current drivers were more likely to be male, younger, have better visual acuity and higher National Eye Institute Vision Function Questionnaire-25 scores. Drivers reported driving an average of 4 days and 10 miles per week. Over 50% of drivers reported that because of their vision, they had difficulty with or did not drive at all in rain, at night, on freeways or interstate highways, in heavy traffic areas, or during rush hour. Drivers and nondrivers did not differ in their life space, the spatial extent of their excursions into their environment. Conclusion. Some individuals who present to a low-vision clinic with age-related maculopathy do drive, although their driving exposure is low and they report avoiding challenging on-road situations. Driving status in age-related maculopathy appears to be related to better eye visual acuity and vision-specific health-related quality of life.

Impact of cataract surgery on health‐related quality of life in nursing home residents

Aim: To assess the impact of cataract surgery in nursing home residents on health-related quality of life, as compared to those who have cataracts but who do not undergo surgery. Methods: A prospective cohort study enrolled 30 nursing home residents (⩾60 years old) who had cataracts and underwent cataract surgery, and evaluated vision-targeted and generic health-related quality of life and depressive symptoms before and approximately 4 months after surgery. This cataract surgery group was compared to 15 nursing home residents who had cataracts but who did not have surgery, over the same timeframe. Results: Visual acuity for near and distance and contrast sensitivity improved following cataract surgery (p<0.001). Adjusting for age differences in the two groups, the cataract surgery group exhibited significant score improvement in the general vision (p = 0.005), reading (p = 0.001), psychological distress (p = 0.015), and social interaction (p = 0.033) subscales of the Nursing Home Vision-targeted Health-Related Quality of Life Questionnaire and the VF-14 (p = 0.004). There were no group differences in the SF-36, Geriatric Depression Scale or the Cataract Symptom Score. Conclusion: Nursing home residents who underwent cataract surgery because of functional problems experienced significant improvements in their vision-targeted health-related quality of life, in addition to dramatically improved vision.

Vision-specific health-related quality of life in age-related maculopathy patients presenting for low vision services.

Few studies have examined the effectiveness of low vision rehabilitation for age-related maculopathy (ARM) patients and its impact on vision-specific health-related quality of life (HRQoL). However, before a multi-site clinical trial can be conducted, appropriate outcome measures need to be identified for ARM patients who seek out low vision rehabilitation, including a vision-specific HRQoL instrument. The 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was developed to assess vision-specific HRQoL for low vision patients, including those with ARM. This study examines the performance of the NEI VFQ-25 among ARM patients who seek out low vision services and examines its relationship with visual acuity and self-reported use of low vision aids. One hundred and twenty-seven patients were recruited from a University-affiliated low vision clinic. During two telephone interviews, subjects completed the NEI VFQ-25 and a short cognitive test and provided information on general health and use of low vision aids. Additional information on visual acuity and eye health were collected from the medical record. Our results indicate that ARM patients who seek out low vision services report significant impairment in their vision-specific HRQoL. Their NEI VFQ-25 scores were lower compared to other ARM and low vision rehabilitation samples previously studied. The VFQ subscales with the largest deficits were near and distance visual acuities and psychosocial issues (near vision, distance vision, role difficulties, dependency, social functioning, mental health). These subscale scores were lower for those with greater visual acuity impairment. The VFQ subscale scores most impacted by the disease had wide variability and were higher for those who used low vision aids, suggesting that the NEI VFQ-25 is suitable for measuring further decline and treatment-related improvements. Thus, it should be strongly considered for a multi-site clinical trial on the effectiveness of low vision rehabilitation.

Vision-specific health-related quality of life: Content areas for nursing home residents

Nursing home residents have a high prevalence of remediable visual impairment and blindness. Future research on the effectiveness of providing eye care to nursing home residents will need to include a vision-targeted health-related quality of life (HRQOL) instrument appropriate for this population. The purpose of this study was to identify the core content areas for such an instrument. In-depth interviews on vision-related issues were conducted with 40 residents. Interviews were audio-taped, transcribed, and coded using a standardized protocol. Binocular distance and near visual acuity were assessed using the residents ‘walking around’ correction to examine whether one vision-specific HRQOL measure could address the needs of residents with ‘good’ and ‘poor’ vision. Overall 1070 vision-related comments were identified. Residents mentioned 315 problem comments that were grouped into 13 categories, including ocular symptoms (18% of comments), reading (15%), general vision (13%), psychological distress (12%), and activities of daily living (ADLs) (7%). Compared to published data on vision-specific content areas most relevant to community based persons, nursing home residents focused more on ocular symptoms and basic ADLs, with no mention of issues related to driving, home care, and finances. The majority of categories mentioned did not differ on the proportion of comments made by those with ‘good’ and ‘poor’ visual acuity, suggesting that one vision-specific HRQOL instrument would be appropriate for residents with varying levels of visual acuity. Future work will focus on developing a vision-specific HRQOL instrument for nursing home residents.

Mobility function in older veterans improves after blind rehabilitation.

This study was conducted to investigate the effects of blind rehabilitation training on self-reported mobility function in visually impaired adults. Mobility function was assessed with a questionnaire administered before and 2 months after subjects completed a comprehensive blind rehabilitation program that included orientation and mobility training. Subjects rated the level of difficulty performing in 26 of 34 mobility situations as significantly lower after rehabilitation. Subjects also rated their confidence as higher after rehabilitation. Substantial improvement occurred in the self-reported mobility function of visually impaired adults after blind rehabilitation and mobility training.

Development of a nursing home vision-targeted health-related quality of life questionnaire for older adults

Purpose: To develop a questionnaire assessing vision-targeted health-related quality of life in older adults residing in nursing homes. Methods: Using content previously identified through structured interviews with nursing home residents, the 57-item Nursing Home Vision-Targeted Health-Related Quality of Life questionnaire (NHVQoL) was drafted with nine subscales—general vision, reading, ocular symptoms, mobility, psychological distress, activities of daily living, activities/hobbies, adaptation/coping and social interaction. Construct validity and internal consistency and test-retest reliability of subscales were evaluated in a sample of adults ≥60 years old residing in nursing homes in Birmingham, Alabama, who had Mini Mental State Exam (MMSE) scores of ≥13. Results: Participants (n=189) had a mean age of 82 years (SD=7.7), were 84% women and 16% men, 24% African-American and 76% Caucasian and had resided in a nursing home for two years on average. All NHVQoL subscales were correlated with subscales from other vision-targeted and generic health-related quality of life instruments (ADVS, 0.43 to 0.85; VF-14, 0.46 to 0.84; SF-36, 0.19 to 0.43). Lower scores were associated with increased depressive symptomatology by the Geriatric Depression Scale (−0.23 to −0.59), increased mobility problems (−0.17 to −0.54), worse distance and near acuity (−0.21 to −0.51) and worse contrast sensitivity (0.20 to 0.50). All subscales had Cronbach α>0.95. Test-retest reliability (two-week period) for subscales ranged from 0.57 to 0.84. Subscale scores did not differ as a function of MMSE scores. Conclusions: The NHVQoL has subscales with good internal consistency reliability and validity. Test-retest reliability is comparable to other questionnaires designed for the nursing home population. This questionnaire may ultimately be useful in understanding the personal burden of visual impairment and eye disease on quality of life and mental health in older nursing home residents and for evaluating the impact of psychosocial and eye care interventions on health-related quality of life in this population.

The Personal Burden of Decreased Vision-Targeted Health-Related Quality of Life in Nursing Home Residents

Objectives: To present the bother subscales of the Nursing Home Vision-Targeted Health-Related Quality of Life Questionnaire (NHVQoL) and to examine their relationship to the original NHVQoL subscales and objective measures of visual function. Method: 395 nursing home residents completed the bother subscales. Associations between bother subscales and original subscales and objectively measured vision were evaluated. Results: Mean bother scores ranged from 1.97 to 2.30, reflecting an average rating of “a little” bother. For 20 NHVQoL items, more than 50% of participants reported “a lot” of bother. All NHVQoL original subscale scores were moderately correlated with bother subscales (p < .0001). Bother subscales and visual acuity were not highly correlated. Discussion: Nursing home residents are bothered by reductions in vision-targeted health-related quality of life. The NHVQoL bother subscales may probe the personal burden of visual problems in this population that is not captured by the original subscales or objectively measuring visual function.