[Simplification of reading for the visually impaired and the blind].
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PURPOSE: To describe the age-, gender-, and cause-specific 5-year incidence of bilateral visual impairment in participants in the Melbourne Visual Impairment Project, Victoria, Australia. METHODS: Participants aged 40 years and older were recruited from Melbourne, Victoria, Australia, by random cluster sampling. The mean age of the 3271 (83% of the eligible) participants was 59 +/- 12 (SD) years. Of the participants, 54% were female. The initial baseline study (1992-1994) was followed by a 5-year incidence study (1997-1999). At both time points of the study, participants underwent a standardized testing procedure. Distance and near vision was tested using logarithm of the minimum angle of resolution (logMAR) charts, followed by refraction if needed. Visual fields were assessed by the 24-2 Humphrey field test (FastPac, Humphrey Field Analyzer; Carl Zeiss Meditec, Dublin, CA). Also, intraocular pressure, ocular motility, dilated ophthalmoscopy, and photography of the lens and the fundus were conducted. Furthermore, an interview included demographic characteristics, history of eye disease, medical history, and medication use. For classification of visual impairment, both visual acuity (VA) and visual fields (VF) examination results were used. Four levels of bilateral presenting visual impairment were defined: mild (VA, <20/40-20/60, and/or VF, homonymous hemianopia), moderate (VA, <20/60-20/200, and/or VF, constriction <20 degrees to 10 degrees from fixation), severe (VA, <20/200-10/200, and/or VF, constriction <10 degrees to 5 degrees from fixation), and profound (VA, <10/200, and/or VF, constriction <5 degrees from fixation). For all participants found to be visually impaired, the major cause was identified. RESULTS: Of the 3040 people eligible to attend follow-up 2594 (85%) participated. Data were available for 2530 (98%) participants. In 105 participants (4.22%; 95% confidence limit 2.58-5.85) some degree of visual impairment developed. The main causes were undercorrected refractive error (59%), age-related macular degeneration, cataract and neuro-ophthalmic disorders (7% each), glaucoma (3%), and diabetic retinopathy (1%). The main cause of severe and profound visual impairment was age-related macular degeneration (37%). CONCLUSIONS: Undercorrected refractive error was the primary cause of new cases of visual impairment in this population. Further research is needed to understand the origin of this and to develop appropriate prevention measures. Age-related macular degeneration is the primary cause of severe or profound vision loss in Australia. This disease requires further investigation for effective cure and preventive strategies.
PURPOSE: To assess the prevalence of refractive error and visual impairment in school-age children in a metropolitan area of southern China. METHODS: Random selection of geographically defined clusters was used to identify children 5 to 15 years of age in Guangzhou. Children in 22 clusters were enumerated through a door-to-door survey and examined in 71 schools and 19 community facilities from October 2002 to January 2003. The examination included visual acuity measurements, ocular motility evaluation, retinoscopy, and autorefraction under cycloplegia and examination of the external eye, anterior segment, media, and fundus. RESULTS: A total of 5053 children living in 4814 households were enumerated, and 4364 (86.4%) were examined. The prevalence of uncorrected, presenting, and best-corrected visual acuity 20/40 or worse in the better eye was 22.3%, 10.3%, and 0.62%, respectively. Refractive error was the cause in 94.9% of the 2335 eyes with reduced vision, amblyopia in 1.9%, other causes in 0.4%, and unexplained causes in the remaining 2.8%. External and anterior segment abnormalities were seen in 1496 (34.3%) children, mainly minor conjunctival abnormalities. Media and fundus abnormalities were observed in 32 (0.73%) children. Myopia (spherical equivalent of at least -0.50 D in either eye) measured with retinoscopy affected 73.1% of children 15 years of age, 78.4% with autorefraction. The prevalence of myopia was 3.3% in 5-year-olds with retinoscopy and 5.7% with autorefraction. Females had a significantly higher risk of myopia. Hyperopia (+2.00 D or more) measured with retinoscopy was present in 16.7% of 5-year-olds, 17.0% with autorefraction. The prevalence of hyperopia was below 1% in 15-year-olds, with both methods. Astigmatism (cylinder of > or = 0.75 D) was present in 33.6% of children with retinoscopy and in 42.7% with autorefraction. CONCLUSIONS: The prevalence of reduced vision because of myopia is high in school-age children living in metropolitan Guangzhou, representing an important public health problem. One third of these children do not have the necessary corrective spectacles. Effective strategies are needed to eliminate this easily treated cause of significant visual impairment.
PURPOSE: To investigate whether the use of night-vision goggles (NVGs) by night-blind people improves their mobility and sense of independence under dark circumstances. METHODS: Twenty night-blind subjects with retinitis pigmentosa were requested to walk predetermined routes at night with and without NVGs. The number of unintended contacts with obstacles (hits) and the percentage of preferred walking speed (PPWS) en route were assessed in three different situations: a darkened indoor corridor; a moderately lit outdoor residential area; and a well-lit outdoor shopping area. Assessments were performed before and after a 5-week training period, during which the subjects practiced using NVGs in their own surroundings, registered their experiences in a journal, and filled out questionnaires. RESULTS: The mean number of hits in the darkened corridor declined from eight to two when NVGs were used. Mean PPWS (34%) did not improve. In the residential area, mean hits declined from eight to practically zero and mean PPWS increased from 60% to 72% (after training to 78%). In the shopping area, subjects walked at 93% PPWS without any hits and showed no improvement with NVGs. Subjective scores revealed a good sense of orientation, feelings of safety and tranquility and an increase in independent mobility when NVGs were used. CONCLUSIONS: Using NVGs seems to improve nighttime mobility in dark outdoor conditions by decreasing unintended contacts with obstacles and increasing walking speed. Use of NVGs increased independent activities in these subjects and was generally positively evaluated for everyday outdoor use.
PURPOSE: To determine the impact of visual impairment on functional vision of children in a rural population of south India. METHODS: A visual function questionnaire (LVP-VFQ) was administered to 1194 children aged 7 to 15 years identified through a systematic random sampling technique from 144 hamlets of Kariapatti in rural south India as part of a larger population-based project. Visual acuity estimations and clinical examinations for morbidity were performed in these 1194 children. A Rasch analysis was performed to validate the use of the instrument in this population. Bootstrap estimates (95% confidence intervals) of the regression coefficients were used to compare visual function scores between children with normal sight and children with uncorrected monocular and binocular visual impairment. RESULTS: The mean age of children was 10.3 +/- 2.1 years. The reliability estimates were 0.82 for person ability and 0.88 for item difficulty parameters, according to the Rasch analysis. A separation index of 2.15 was obtained for person measures and 2.74 for item measures, and the mean square infit and outfit statistics were 1.03 (Z(STD) 0.1) and 0.99 (Z(STD) -0.1), respectively. Children with monocular visual impairment (bootstrap estimate [95%CI] -0.05 [-0.08 to -0.01]) and binocular visual impairment (bootstrap estimate [95%CI] -0.09 [-0.11 to -0.07]) were more likely to have functional visual deficits than were normally sighted peers. CONCLUSIONS: Monocular or binocular visual impairment impacts on the functional vision of children in this rural population. Further studies are needed to determine the impact of treatment of visual impairment on functional vision in children of this population.
PURPOSE: Visually impaired people are permitted to use bioptic telescopes for driving in many states in the United States. However, it has been suggested that the telescope is used only to meet the visual acuity criteria for licensure. In this study, a survey was used to establish the extent to which bioptic telescopes are used by and meet the driving needs of people with moderately reduced visual acuity. METHODS: A cross-sectional survey of a convenience sample of 58 bioptic drivers was administered by telephone interview. Bioptic telescope usage patterns were quantified with questions designed specifically for the study. Driving patterns were quantified by use of the Driving Habits Questionnaire. Subjects were recruited from four sources across the United States to ensure a range of bioptic training and driving experience. RESULTS: The majority (74%) rated the bioptic telescope as very helpful, and almost all (90%) would continue to use it for driving, even if it were not required for driving licensure; however, only 62% reported always wearing the bioptic when driving. Subjects had relatively unrestricted driving habits, driving a mean of 222 +/- 211 miles per week, and 85% aged < or =65 years drove to work. With the exception of driving in rain, in bright sunlight, and at night, there was little difficulty with driving in a variety of situations, and levels of driving avoidance due to vision impairment were low (<10%). CONCLUSIONS: The bioptic telescope met the (self-reported) driving needs of the majority of visually impaired drivers in this survey and was found to be a useful aid for tasks requiring resolution of detail.
PURPOSE: To determine the impact of vision impairment and eye diseases on vision-specific quality of life and visual function in an older population of rural southern India. METHODS: Presenting and best-corrected visual acuity and burden of eye diseases were determined in a population aged 40 years and older, identified through a random cluster sampling strategy from 50 villages of rural south India. A questionnaire validated previously for use in this population was used to ascertain quality of life and visual function. Visual acuity measurements were obtained with illiterate E Early Treatment Diabetic Retinopathy Study (ETDRS) charts. Cataract was graded and defined based on the Lens Opacities Classification System (LOCS) III. Macular degeneration was defined based on the classification system proposed by the International ARM Epidemiologic Study Group. Glaucoma was defined based on results of clinical examinations including optic disc and visual fields. Analyses were performed to explore the relationship of overall and subscale quality-of-life and visual function scores with presenting acuity in the better-seeing eye, specific eye diseases, and demographic variables. RESULTS: Information on quality of life and visual function were available for 5119 (99.4%) of 5150 study subjects. The mean presenting visual acuity in the better eye was 0.76 +/- 0.53 logMAR (logarithm of the minimum angle of resolution) units. Age, education, occupation, presenting acuity in the better eye, and presence of a cataract, glaucoma, or refractive error were independently associated with overall quality-of-life and vision function scores. After adjustment for demographic variables and ocular disease, persons with vision impairment or bilateral blindness based on presenting visual acuity had lower scores across all domains of quality of life and vision function. Scores for subscales of quality-of-life and vision function domains were significantly lower among those with age-related cataract and glaucoma compared with persons without those eye diseases. CONCLUSIONS: Presenting vision in the better eye was associated with quality of life and vision function in this older population of rural south India. Subjects with glaucoma and age-related cataract had an associated decrease in quality of life and vision function, independent of presenting visual acuity in the better eye.
PURPOSE: To evaluate the association between the density of nuclear, cortical, and posterior subcapsular lens opacities and visual impairment in patients with cataract. METHODS: In 80 patients, visual acuity and reading performance were evaluated 1 day before and 4 weeks after cataract surgery. Cataracts were categorized and graded according to the Lens Opacities Classification System (LOCS) III of nuclear color (NC), nuclear opalescence (NO), cortical (C), and posterior subcapsular cataract (P). A multiple linear regression analysis and partial correlation coefficients were calculated. Data were also checked for significant pre- and postoperative differences in visual performance related to cataract grading. RESULTS: In the multiple linear regression analysis, significant associations were found between the improvement in visual acuity and reading performance after cataract surgery and the NC, NO, and P scores (P < 0.001); no significant association was found for the C score (P > 0.05). High partial correlation coefficients were found between the P score and the preoperative visual acuity (r = 0.6; P < 0.001), reading acuity (r = 0.74; P < 0.001), and maximum reading speed (MRS; r = -0.77; P < 0.001). Significant but lower partial correlation coefficients were found for the NO score. No significant partial correlation coefficients were found for the NC and C score. Significant pre- and postoperative differences in MRS were found in patients with P scores > or =3 or NO and NC scores > or =5, representing functionally relevant impairment. CONCLUSIONS: A strong association was found between visual impairment in patients with cataract and the severity of posterior subcapsular cataract (PSC) and nuclear opacity. Particularly in patients with PSC, deficits in reading performance significantly increased. The functionally relevant deficits in patients with P scores > or =3 or NO and NC scores > or =5, should be carefully considered for planning cataract surgery or visual rehabilitation.
PURPOSE: To investigate the underestimation of field loss in functional field score (FFS) between the Goldmann isopters III-4e and V-4e in visually impaired patients, in order to develop a predictive model for the FFS(III-4e) based on FFS(v-4e) that adjusts for possible confounders. Although the visual field is generally evaluated using Goldmann isopter III-4e, it has the disadvantage that not all low-vision patients are able to see the stimulus corresponding to this isopter. METHODS: Goldmann visual fields were obtained from 58 patients with a variety of eye diseases. Eligibility criteria were age of 18 years or older and valid results of a Goldmann III-4e and V-4e visual field test in at least one eye. Linear regression was used to develop the model, setting FFS(III-4e) as the dependent variable and FFS(V-4e) as the independent one. RESULTS: The FFS(V-4e) was higher than the FFS(III-4e), the mean difference being 14.56 points (95% CI, 12.48 -16.64). Multiple linear regression analysis showed that age, functional acuity score, primary eye disease, and central-peripheral loss were not confounders for the prediction of FFS(III-4e). FFS(III-4e) was estimated with the following equation: FFS(III-4e) = -19.25 + 1.063 x FFS(V-4e). CONCLUSIONS: The relationship between FFS(III-4e) and FFS(V-4e) is linear, and the FFS(V-4e) can be used to estimate the FFS(III-4e). In practice, just subtracting 19.25 points of the value of FFS(V-4e) will be sufficient to estimate the value of FFS(III-4e). This model should give confidence about using the bigger isopter for determining the visual impairment of a person by the FFS.
PURPOSE: To identify the content for a vision and quality of life-related utility measure (Vision Quality of Life Index [VisQoL]) for the economic evaluation of eye care and rehabilitation programs. METHODS: Focus groups of the visually impaired elicited key concepts. Based on these and previous research, 33 items were generated. These were administered to visually impaired adults (n = 70) and a representative sample of unimpaired adults (n = 86). The item bank was reduced through examination of item properties, exploratory factor (EFA), item response theory (IRT), and structural equation modeling (SEM) analyses. The resultant model was confirmed through administration to a second sample of participants. RESULTS: Focus group themes included physical well-being, social well-being, independence, self-actualization, emotional well-being, and planning and organization. Poorly performing items were eliminated on basic psychometric properties, including failure to discriminate. Next, EFA loadings were used to select items. Twelve items survived. To minimize redundancy, IRT analysis and SEM reduced the VisQoL item pool to six items (Cronbach alpha = 0.88). To confirm this model, these items were then administered to an additional 218 participants; 35% with a vision impairment. A pooled SEM analysis showed the model to have very good fit properties (root mean square error of approximation [RMSEA] = 0.000). A preliminary test of the model against visual acuity showed a significant monotonic relationship. CONCLUSIONS: The short 6-item VisQoL has excellent psychometric properties as a simple summative instrument. It can be used in its present state as a condition-specific outcome measure for the evaluation of healthcare interventions for the visually impaired. The descriptive model is also suitable for generating utility values for the economic evaluation of vision-related programs and services.
PURPOSE: To estimate health status utility values in patients with age-related macular degeneration (ARMD) associated with visual impairments, by using preference-based measures of health. METHOD: This was a cross-sectional study involving patients with unilateral or bilateral ARMD who attended a large teaching hospital. Patients underwent visual tests (near and distant visual acuity [VA] and contrast sensitivity [CS]) and completed health status questionnaires including the Index of Visual Function (VF)-14 and three preference-based measures (the Health Utilities Index Mark III [HUI-3], the EuroQoL Health Questionnaire [EQ-5D], and the Short Form 6D Health Status Questionnaire [SF-6D]) and the time tradeoff (TTO). The mean health status is presented for five groups, defined according to the VA in the better-seeing eye and for four CS groups. RESULTS: Two hundred nine patients were recruited with substantial loss of visual function as obtained by visual tests (mean decimal VA in the better-seeing eye: 0.2) and self-report (mean VF-14 score: 41.5). The mean (+/-SD) utilities were 0.34 +/- 0.28 for HUI-3, 0.66 +/- 0.14 for SF-6D, 0.72 +/- 0.22 for EQ-5D, and 0.64 +/- 0.31 for TTO. The HUI-3 had the highest correlation with VA and CS (0.40 and -0.34), followed by TTO (0.25 and -0.21). Across the VA and CS groups, only HUI3 and TTO had a significant linear trend (P < 0.05). In a regression model with CS and VA as explanatory variables, only the coefficient on CS was statistically significant. CONCLUSIONS: ARMD is associated with a substantial impact on patients' health status, but this was not reflected in two of the generic preference-based measures used. The HUI-3 seems to be the instrument of choice for use in economic evaluations in which community data are needed. It may be more appropriate to base economic models on CS or some combination of CS and VA rather than on VA alone.
PURPOSE: To investigate self-reported difficulties experienced by visually impaired subjects in real-world tasks requiring judgment of space and distance and to determine whether laboratory measures of spatial localization predict self-reported difficulty with spatial tasks better than traditional measures of visual function, such as visual acuity and contrast sensitivity. METHODS: Forty-two subjects with visual impairment participated. The Spatial Localization Questionnaire (SLQ) was developed to investigate self-reported spatial localization difficulties, and subjects answered the questionnaire as part of the study. Subjects also completed a variety of clinical vision tests (visual acuity, contrast sensitivity, stereo acuity, and reading speed) and laboratory vision tests (vernier acuity, bisection acuity, and visual direction). RESULTS: The SLQ was found to have good validity. Several significant correlations were found between the Rasch analysis ability scores for the questionnaire and the clinical and laboratory vision tests. Using stepwise regression analysis, we found that vernier acuity and contrast sensitivity accounted for 42% of the variance in the Rasch scores (P < 0.001). CONCLUSIONS: The findings indicate that certain subjects with visual impairment have difficulty with real-world spatial tasks, as indicated by the SLQ. Of note, these difficulties were better predicted by vernier acuity (a resolution test) and contrast sensitivity, rather than vernier or bisection bias, which measure localization.
PURPOSE: To evaluate the association of cortical, nuclear, or posterior subcapsular (PSC) cataract with dietary intake of lutein-zeaxanthin (LZ) in a population-based sample. METHODS: For the study, 3271 (83% of the eligible residents) permanent residents aged > or =40 years were recruited in 1992 to 1994 via a cluster random sampling. In 1997 to 1999, 2594 (79%) attended the follow-up examination including lens photography, a life-style questionnaire, and a food-frequency questionnaire (FFQ). Cases were those with cortical opacity > or =4/16, nuclear opacity grade > or =2.0, or PSC opacity > or =1 mm2. Logistic regression was used to calculate the odds ratios for cataract by daily LZ intake, or its quintile indicator with the lowest quintile as the baseline category, controlling for energy-adjusted fat intake and variables previously found to be associated with the cataract outcomes. RESULTS: Of the 2322 participants who attended the follow-up survey and completed the FFQ, 1841 (79%), 1955 (84%), and 1950 (84%) were included in the analyses of cortical, nuclear, and PSC cataract, respectively. There were 182 (9.9%), 387 (19.8%), and 177 (9.1%) cases for cortical, nuclear, and PSC cataract, respectively. Cortical and PSC cataract were not significantly associated with LZ intake. For nuclear cataract the odds ratios were 0.67 (0.46-0.96) and 0.60 (0.40-0.90) for every 1-mg increase in crude and energy-adjusted daily LZ intake, respectively. The odds ratios (95% CI) for those in the top quintile of crude LZ intake was 0.58 (0.37-0.92; P = 0.023 for trend), and it was 0.64 (0.40-1.03) for energy adjusted LZ intake (P = 0.018 for trend). CONCLUSIONS: This study found an inverse association between high dietary LZ intake and prevalence of nuclear cataract.
PURPOSE: Several studies indicate an increased mortality rate in older adults who have visual impairment, but few have attempted to address a potential causal mechanism. The goals of this study are to determine whether visual acuity loss increases the risk of dying and to examine whether depressive symptoms act as a mediator in this relationship. METHODS: Data were derived from the 2520 older adults who participated in the Salisbury Eye Evaluation project, a population-based prospective 8-year cohort study. Presenting binocular visual acuity was measured with the Early Treatment Diabetic Retinopathy Study [ETDRS] eye chart and depressive symptoms with the General Health Questionnaire Part D subscale. Mortality data were collected by staff follow-up. Analyses were performed with the Cox proportional hazards regression. RESULTS: Worse baseline acuity was associated with a higher mortality rate (hazard ratio [HR] = 1.05; 95% confidence interval [CI], 1.01-1.09). Also, those who gained two or more lines of visual acuity over 2 years had a lower adjusted risk of dying (HR = 0.47; 95% CI, 0.23-0.95). An interaction was detected, in that women who lost > or =3 lines of visual acuity over a 2-year period had a higher adjusted risk of dying (HR = 3.97; 95% CI, 2.21-7.15), whereas men did not (HR = 1.32; 95% CI, 0.66-2.63). Depressive symptoms did not mediate these relationships. CONCLUSIONS: If the relationship between visual acuity and mortality is indeed causal, it most likely acts via numerous pathways through a variety of intervening variables. The identification of these intervening variables could give additional targets for intervention if acuity cannot be restored.
PURPOSE: To determine the impact of visual impairment and eye diseases on quality of life (QOL) in an older population of Andhra Pradesh in southern India. METHODS: The World Health Organization (WHO) QOL (WHOQOL) instrument was adapted as a health-related quality of life (HRQOL) instrument for administration to adults participating in the Andhra Pradesh Eye Disease Study. Participants aged 40 years and older (n = 3702), 99.4% of the 3723 eligible, who underwent interview and detailed dilated ocular eye evaluation by trained professionals were included in this study. Psychometric properties of the HRQOL instrument were evaluated among visually impaired people. Relationships among overall QOL scores and presenting visual acuity in the better eye, specific eye diseases, and demographic variables were examined. RESULTS: Internal consistency was high for the entire questionnaire (alpha = 0.94). Each item of the QOL scale had an adequate item-total correlation (range, 0.25-0.77) greater than 0.2. After adjusting for demographic variables and ocular disease, Subjects with blindness had significantly lower QOL scores. Subjects with glaucoma or corneal disease independent of visual acuity had lower scores than subjects without those eye diseases. Subjects with cataract or retinal disease had significantly lower scores than those without cataract or retinal disease in the model without visual acuity but not when visual acuity was added to the model. CONCLUSIONS: Decreased QOL was associated with the presence of glaucoma or corneal disease independent of visual acuity and with cataract or retinal disease as a function of visual acuity. Visual impairment from uncorrected refractive errors was not associated with decreased QOL.
PURPOSE: To explore the psychometric properties of the Impact of Vision Impairment scale (IVI) by using Rasch analysis. METHODS: Three hundred fourteen first-time referrals to low-vision clinics completed the 32-item IVI. The data were Rasch-analyzed with a partial credit model using RUMM2020 software (RUMM Laboratory, Perth, WA, Australia). The overall fit of the model, response scale, individual item fit, differential item functioning, unidimensionality, and person-separation reliability were assessed. RESULTS: Initially, 26 items displayed disordered thresholds. However, collapsing the response scale to three categories (4 items) and four categories (28 items) produced ordered response thresholds for all items. Four items with high proportions of missing responses, poor spread, high skewness, and deviation between observed and expected model curves were then removed. This adjustment produced overall fit to the Rasch model (item-trait interaction chi(2) = 118.3; P = 0.32). The final mean (SD) person and item fit residuals ere 0.06 (0.85) and -0.20 (1.45), respectively. The person-separation reliability was 0.9, indicating that the scale was able to discriminate between several different groups of participants. The revised scale was well targeted to the participants, with similar mean locations for items (0.00) and persons (0.16). A significant difference between participants of mild, moderate, and severe visual impairment (ANOVA; P 0.001) supported the criterion validity of the Rasch-scaled IVI. CONCLUSIONS: The results provide support for the measurement properties of the Rasch-scaled 28-item version of the IVI and of its potential for assessing outcomes of low-vision rehabilitation. A raw score-to-Rasch person measure conversion is supplied.