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We also explored whether monocular impairment (presenting acu-

ity in the worse eye worse than 20/40 and acuity in the fellow eye of

20/40 or better) influenced quality-of-life domains. Participants with

presenting acuity in the better eye of 20/40 or better were used in the

analysis, and comparisons were made between those with no impair-

ment (both eyes had 20/40 or better acuity) and those who had

monocular impairment (one eye had worse than 20/40 acuity). In

addition, we adjusted for acuity in the better eye, because those with

monocular impairment were more likely to have lower presenting

acuity in the better eye than those without impairment.

Also assessed were the individual contributions of glaucoma, DR,

cataract, and refractive error on quality-of-life-domains. In afirst model,

we assessed these additive contributions without accounting for acuity

impairment, to determine the contribution a particular disease has on

quality of life. Those with any of these eye diseases or refractive error

were compared with those with no evidence of eye disease nor

refractive error. However, eye disease per se would not be expected to

impact on quality of life unless there were an associated impact on

some aspect of vision. In a second model, we tested this hypothesis by

evaluating the additive contributions of eye disease (glaucoma, DR,

and/or cataract) on quality of life, with adjustment for presenting

acuity. In a third analysis, we added to the model second-order inter-

action terms between eye disease variables, to observe whether dec-

rements in quality of life due to eye disease acted additively, orwhether extra decrements occurred when two diseases were present.

Participants with vision loss not due to glaucoma, DR, or cataract (e.g.,

macular degeneration, amblyopia, trauma) were excluded from these

analyses because there were small numbers of people in these catego-

ries.

Because the data are from a cross-sectional sample, all inferences

regarding the relationship of acuity and quality-of-life scores refer to

the comparison of quality-of-life measures between individuals with

different levels of acuity. Use of the wordsdecrement, decline,or

loss are meant only to describe the relationship between the mea-

sures of interest, rather than to imply a longitudinal shift in quality of

life with a change in vision (or other measure).

Preliminary analysis showed that some NEI-VFQ-25 subscales had a

potentially nonlinear relationship with presenting acuity: Distance

Vision, Driving, and Mental Health. For these subscales, we allowed theslope of presenting acuity to change for acuity worse than 20/40

(spline regression).

Subscale score distributions were skewed toward the higher scores

(e.g., ratings of excellent or no difficulty), resulting in linear model

residuals that were independent but non-normally distributed. Confi-

dence intervals will suggest false significance, because the standard

error calculation from such models is based on residuals that are

normally distributed. To better characterize the variation of the param-

eter estimates, we performed a nonparametric bootstrap on all models.

A participants information was drawn at random, with replacement,

from the observed values. Estimates from the linear models were

calculated (a bootstrap estimate), and this process was repeated to

create 1000 bootstrap estimates. A 95% bias-corrected confidence

interval, was calculated, using the 2.5th and 97.5th percentiles of thebootstrap distributions.

RESULTS

Of the 4774 participants in the study, 13 (0.3%) had question-naires completed by proxy and 7 participants refused to un-dergo measurement of refraction. Of the remainder, 175 par-ticipants did not receive a complete eye disease assessment,and 29 were diagnosed with eye disease other than glaucoma,DR, or cataract. These latter two groups totaling 204 wereexcluded from the analyses of eye disease and quality of life.

The average age for our sample was 56.9 years (range,40 96; Table 2). Approximately two thirds of this sample had

a yearly income below $20,000 and had less than a high school

education. The participants had low acculturation scores, witha mean of 1.99 0.95 (SD). Almost 80% chose to take thequestionnaire in Spanish.

Table 3 describes the average decrement in score for each2 lines of presenting acuity lost for each subscale of the NEI-VFQ-25. In all domains, scores showed significant decline asthe logMAR increased, after adjustment for demographic vari-ables. The slope change was the steepest in the domains ofRole Difficulties (6.23 change in score per 2 lines lost),Dependency (5.27 change in score per 2 lines lost), and NearVision (5.26 change in score per 2 lines lost). For subscaleswith nonlinear associations with acuity, there were signifi-cantly steeper declines for those with vision worse than 20/40,especially in the Driving subscale, which showed a decline of11.6 for every 2 lines lost.

Of the 4368 participants with presenting acuity in thebetter eye of 20/40 or better, 663 (15.2%) had acuity worsethan 20/40 in the other eye (monocular impairment). Thosewith monocular impairment had average presenting acuity inthe better eye of 0.12 0.13 (SE) logMAR. In those with noimpairment, average presenting acuity in the better eye was0.04 0.11 logMAR. Monocular impairment was associatedwith a modest decrease in quality of life, in all domains exceptGeneral Health, Near Vision, Color Vision, and Ocular Pain(Table 4). The greatest decrements in scores of those withmonocular impairment occurred in the visual tasks of Driving(5.68) and General Vision (3.44), as well as in Role Func-tion (4.43).

Subjects with cataract had mean better-eye acuity compara-ble to the acuity of those with glaucoma and DR (Table 5).

Most persons with cataract had PSC only (149/374; 39.8%) or

TABLE2. Characteristics of Mexican-American Participants inProyecto VER

Characteristic Category n (%)

Presenting acuity inbetter eye 20/40 or better 4368 (91.9)

Between 20/41 and 20/199 363 (7.6)20/200 or worse 23 (0.5)

Age at time of clinicexam (y) 4049 1591 (33.4)

5059 1361 (28.6)6069 982 (20.6)7079 631 (13.3)80 195 (4.1)

Gender Male 1841 (38.7)Female 2920 (61.3)

Yearly income $20,000 3151 (66.2)$20,000 1492 (31.3)

Education 12 years 3101 (65.1)12 years 1660 (34.9)

Acculturation Score 12 2763 (58.0)23 972 (20.4)34 942 (19.8)44.5 84 (1.8)

Location Nogales 1620 (34.0)

Tucson 3141 (66.0)Current Drivers 3522 (74.0)Medical Insurance 3192 (67.1)Hypertension 2085 (56.2)Glaucoma 100 (2.1)Diabetic retinopathy 290 (6.3)Cataract 374 (8.0)Other eye disease 29 (0.6)Uncorrected

refractive error 405 (8.5)

n 4761 clinic participants with self-completed questionnaires,4550 (96%) of these received complete eye examinations.

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mixed cataract (86/374; 23.0%), with the greatest acuity im-pairment in those with nuclear cataract (average, 0.29 logMAR)and mixed cataract (average, 0.36 logMAR).

After adjustment for demographic variables, those withglaucoma, DR, cataract, and uncorrected refractive error werefound to have lower scale scores than those without disease ingeneral (Table 6). Those with glaucoma had significantly lowerscores in all domains except General Health and Ocular Painthan did those with no eye disease. Those with DR had signif-icantly lower scores in all domains. The largest decrease oc-curred in General Health, which was expected, because theseparticipants had diabetes. Those with glaucoma or DR re-ported larger decreases in the areas of Near and DistanceVision, Driving, and Peripheral Vision and in the psychosocialdomains of Role Difficulties, Dependency, Social Function, andMental Health than did those with cataract or uncorrectedrefractive error.

The association of eye disease with quality-of-life-domainswas not as strong after adjustment for presenting acuity; how-

ever, there still were significant effects of disease (Table 7). Forglaucoma, the difference in scores after adjustment for acuitywas modest, in most cases only one point or less different fromscores that were not adjusted for acuity. For DR, the change inscores was slightly greater (except for General Health), but stillthe overall decrement in scale scores with DR was large, afteradjustment for acuity. None of the scale scores was signifi-cantly different between those with cataract and those with noeye disease, except in Driving, after adjustment for acuity. Thissuggests that the effect of cataract on quality of life in thispopulation was due to the effect on decreasing acuity.

The models that included interactions between glaucoma,cataract, and DR, suggested that multiple eye disease wasassociated with additional decrements in quality of life, beyondthe additive decrements associated with each disease sepa-rately. Table 8 shows the proportion of our participants withdifferent combinations of eye disease. After adjustment fordemographic variables, there was a significant additional dec-rement in score (range, 20.2 to 8.5,P 0.05) in the scalesof Near and Distant Vision, Driving, Ocular Pain, Role Func-tion, Dependency, Mental Health, and Color Vision for thosewith both glaucoma and cataract. There was a significant de-crease in Driving, Role Function, and Dependency (range,17.8 to 14.5, P 0.05) for those with glaucoma and DR,and there was also a significant decrease in the Driving score(8.7,P 0.04) for those with DR and cataract. However, thenumber of persons with combinations of eye disease was smalland did not permit more detailed analyses.

DISCUSSION

Visual acuity impairment was significantly associated with adecrement in all measured domains of self-reported, vision-related quality of life in this sample of Mexican-Americans. For

TABLE4. Degree of Decrement in Subscale Scores of Those withMonocular Presenting Acuity Impairment, Compared with Those

with 20/40 or Better Acuity in Both Eyes

NEI-VFQ Subscale

Monocular Impairment

Est.Bootstrap

95% CI

General health 0.42 ( 2.97 to 1.74)General vision 3.44* ( 5.03 to 1.94)Near vision 1.39 ( 3.18 to 0.54)Distance vision 2.45* ( 4.07 to 0.85)Driving 5.68* ( 8.24 to 3.19)Peripheral vision 3.02* ( 4.92 to 1.25)Color vision 0.55 ( 1.67 to 0.45)Ocular pain 0.76 ( 2.62 to 1.22)Role difficulties 4.43* ( 6.64 to 2.28)Dependency 2.34* ( 3.99 to 0.76)Social functioning 2.08* ( 3.21 to 1.03)Mental health 2.69* ( 4.48 to 0.83)

All models are adjusted for presenting acuity in the better eye, age,gender, acculturation, income, education level, location, and medicalinsurance. Est., estimate.

* Indicates a significant estimate.

TABLE5. Comparison of Mean LogMAR Acuity in the Better Eye ofParticipants with Cataract, Glaucoma, or DR

Disease n Mean Acuity Range

Cataract 374 0.21 0.261.7Glaucoma 100 0.22 0.181.7DR 290 0.12 0.31.5

TABLE3. Relationship of Presenting Acuity in the Better Eye to Scale Scores of The NEI-VFQ 25, Adjusting for Demographic Factors

NEI-VFQ Subscale

Change in Scale Score with Additionof 2 Lines of Acuity Loss*

Change in Scale Score with Additionof 2 Lines of Acuity Loss for Acuity

Worse Than 20/40

Est.Bootstrap

95% CI Est.Bootstrap

95% CI

General health 1.84 ( 2.65 to 1.10)General vision 3.60 ( 4.28 to 2.99)Near vision 5.26 ( 6.05 to 4.50)Distance vision 3.78 ( 4.61 to 2.95) 8.60 ( 10.2 to 6.93)Driving 4.49 ( 5.72 to 3.33) 11.65 ( 15.0 to 8.68)Peripheral vision 3.77 ( 4.63 to 2.99)Color vision 2.67 ( 1.76 to 3.55)Ocular pain 2.67 ( 3.52 to 1.94)Role difficulties 6.23 ( 7.14 to 5.31)Dependency 5.27 ( 6.17 to 4.28)Social functioning 3.39 ( 4.20 to 2.63)Mental health 3.66 ( 4.73 to 2.59) 9.00 ( 10.7 to 7.13)

All models are adjusted for age, gender, acculturation, income, education level, location, and medical insurance. Est., estimate.* There is a 3-line difference between 20/20 acuity and 20/40 acuity.For these domains, the slope changed significantly after 20/40, and we show the decline after that point (spline regression).

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some physical tasks, related to driving and distance vision,steeper decreases in scores were observed once presentingacuity was worse than 20/40. Steeper declines in the mentalhealth scale were also observed. These data suggest that self-reported decrement in quality of life was present even withmodest visual loss, and that there was no threshold effect. Thefinding of a modest decrement in scores among those withmonocular impairment with better-eye presenting acuity of20/40 or better, further supports this statement.

Participants with glaucoma reported difficulties with driv-ing and tasks of peripheral vision and feelings of dependency.The restrictions on independent functioning imposed by driv-ing difficulties may have contributed to reports of low scores independency. The scores changed only slightly after adjustmentfor acuity, which was expected because glaucoma affects pe-

ripheralfield before centralfield. Most persons with glaucomado not lose central acuity until late in the course of disease(although, in this population, glaucoma was the leading causeof blindness21).

Participants with DR reported low scores in all domains,especially in general health. These participants, by definition,all had diabetes, and therefore low scores in health wereexpected. It is interesting that those with DR also reported lowscores in near and distance tasks and that most of these diffi-

culties were not explained by decreased acuity. A furtheranalysis of the impact of DR on other measures of vision iswarranted, because decrement in ability to perform these func-tions may explain decrements in quality of life better thanimpairment of acuity.

We have shown in previous work that the impact on self-reported physical function with loss in multiple measures ofvisual function is additive.22 For example, decreases in acuityand loss of visualfields produced additive effects on difficultieswith physical function. In this study, we observed that the impactof cataract on quality of life was largely mediated through itseffect on acuity alone. However, glaucoma and DR probablyhave other effects, apart from acuity, that have an impact onquality of life. Our findings are consistent with our previouswork, in that those with glaucoma and DR were associated

with larger decrements in scale scores than those with cataract.Mangione et al.12 found similar results, in that patients with

glaucoma, DR, and cataract had lower scores in all domainsthan did those with no evidence of eye disease. It is interestingthat those with uncorrected refractive error reported decre-ments in quality of life that were comparable to decrementsreported by participants with cataract. A prospective studywould determine whether provision of adequate correctionwould result in improvement in function in all these domains.

TABLE6. Effect of Eye Disase on NEI-VFQ-25 Scale Scores, Compared with Those with No Eye Disease, and Adjustingfor Demographic Variables

NEI-VFQ Scale

Glaucoma Diabetic Retinopathy Cataract Uncorrected

Refractive Error

Est.Bootstrap




95% CI

General health 1.81 ( 7.0 to 3.4) 16.0* ( 18.8 to 13.5) 0.09 ( 2.65 to 2.59) 0.67 ( 1.79 to 3.73)General vision 6.30* ( 10.6 to 1.89) 4.74* ( 6.76 to 2.74) 2.74* ( 4.78 to 0.88) 2.58* ( 4.50 to 0.78)Near vision 9.01* ( 14.5 to 2.87) 8.44* ( 11.4 to 5.58) 2.87* ( 5.74 to 0.38) 5.07* ( 7.58 to 2.88)Distance vision 9.60* ( 15.3 to 3.62) 8.64* ( 11.4 to 5.90) 3.75* ( 6.51 to 1.45) 4.67* ( 6.80 to 2.69)Driving 17.0* ( 28.2 to 6.04) 11.7* ( 15.9 to 7.60) 4.60* ( 8.54 to 1.37) 3.09* ( 6.23 to 0.07)Peripheral vision 9.46* ( 15.2 to 3.99) 6.22* ( 9.02 to 3.55) 1.62 ( 4.16 to 0.67) 1.98 ( 3.97 to 0.005)Color vision 5.78* ( 11.1 to 1.14) 2.54* ( 4.77 to 0.93) 0.83 ( 2.89 to 0.81) 1.12 ( 2.82 to 0.26)Ocular pain 4.05 ( 9.48 to 0.49) 2.92* ( 5.53 to 0.23) 1.22 ( 1.29 to 3.75) 3.07* ( 5.60 to 0.63)Role difficulties 10.2* ( 13.8 to 6.87) 10.2* ( 13.8 to 6.87) 4.40* ( 7.53 to 1.47) 5.51* ( 8.64 to 2.88)Dependency 14.6* ( 22.1 to 7.97) 8.70* ( 12.1 to 5.87) 2.87* ( 5.88 to 0.51) 3.79* ( 6.32 to 1.66)Social functioning 8.04* ( 13.1 to 3.39) 4.92* ( 7.14 to 2.64) 1.62 ( 3.57 to 0.05) 1.99* ( 3.52 to 0.51)Mental health 12.7* ( 19.3 to 6.95) 9.73* ( 13.0 to 6.46) 3.19* ( 6.00 to 0.55) 5.24* ( 7.86 to 2.82)

* Indicates a significant estimate (Est.).

TABLE7. Effect of Eye Disease on NEI-VFQ-25 Scale Scores, Adjusted for Presenting Acuity and Other Demographic Variables

NEI-VFQ Subscale

Glaucoma Diabetic Retinopathy Cataract

Est.Bootstrap



95% CI

General health 1.39 ( 6.49 to 3.87) 15.6* ( 18.5 to 13.2) 0.53 ( 2.09 to 3.20)General vision 5.14* ( 9.31 to 1.21) 3.75* ( 5.68 to 1.68) 1.23 ( 3.13 to 0.56)Near vision 7.69* ( 12.6 to 2.10) 6.96* ( 9.88 to 4.24) 0.89 ( 3.75 to 1.50)Distance vision 7.88* ( 13.4 to 2.68) 6.99* ( 9.62 to 4.38) 1.41 ( 3.93 to 0.81)Driving 14.8* ( 25.4 to 4.32) 10.1* ( 14.4 to 6.32) 3.65* ( 7.45 to 0.38)Peripheral vision 8.47* ( 14.0 to 3.23) 5.14* ( 7.92 to 2.65) 0.17 ( 2.60 to 2.06)Color vision 5.19* ( 10.4 to 0.94) 1.87* ( 4.04 to 0.26) 0.09 ( 1.84 to 1.68)Ocular pain 3.18 ( 8.57 to 1.19) 2.16 ( 4.70 to 0.49) 2.35 ( 0.12 to 4.87)Role difficulties 9.58* ( 15.4 to 3.63) 8.55* ( 11.7 to 5.38) 2.03 ( 4.88 to 0.97)Dependency 13.0* ( 20.3 to 6.94) 7.28* ( 10.4 to 4.58) 0.84 ( 3.57 to 1.42)Social functioning 7.28* ( 12.0 to 2.97) 4.07* ( 6.19 to 1.99) 0.45 ( 2.35 to 1.26)Mental health 10.5* ( 16.4 to 4.97) 8.15* ( 11.3 to 5.28) 0.62 ( 3.24 to 1.93)

* Indicates significant estimate (Est.)

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Although it is reasonable to suppose that difficulties in tasksembedded in the near distance and driving scales would beresolved with adequate correction, the impact on psychologi-cal and social function is not clear and deserves study.

Having more than one eye disease appeared to have amultiplicative effect in most domains, especially in participantswith glaucoma and cataract. This finding suggests that remov-ing cataract in the presence of other eye disease may signifi-cantly improve quality of life in these subjects.

A main limitation in our analysis of visual impairment andvision-related quality of life was the availability of data only oncentral acuity impairment. Clearly, visual impairment may havemultiple dimensions, such as loss of contrast sensitivity, pe-ripheralfield, stereo acuity, and other measures.23 We did notcapture other aspects of visual impairment, except for visualfields, which were used in the diagnosis of glaucoma. Decre-ments in these other aspects of vision may correlate moreclosely with decrements in specific domains. Also, we did notcollect detailed comorbidity information from participants. In-formation such as hearing loss, heart disease, arthritis, or strokemay have been useful in also predicting declines in domainssuch as Social Function and Dependency. Obviously, increas-ing severity of disease would have some impact on vision andthus an increasing impact on quality of life, but we did not

make such an analysis. We also did not address disease-specificissues, such as the effect of visual field loss on quality of life inthose with glaucoma.

In summary, our data suggest that visual acuity impairment,in both the better- and the worse-seeing eyes, was associated witha decrease in quality of life within the Mexican-American sam-ple studied, and the steepness of that decrease was associatedwith level of visual impairment. Uncorrected refractive error,cataract, DR, and glaucoma all were associated with decrementsin quality of life, many not explained by the impact of acuity.Further longitudinal studies on the impact of remediation ofvision loss on quality of life in this population are warranted.

Acknowledgments

The authors thank Gary Rubin, Karen Bandeen-Roche, and the anony-mous referees for their advice and input; and team of Proyecto VER for

their skill and support.

References

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American population: Proyecto VER. Invest Ophthalmol Vis Sci.2002;43:608 614.

3. West SK, Klein R, Rodriguez J, et al. Diabetes and diabetic retinop-athy in a Mexican-American population: Proyecto VER. DiabetesCare.2001;24:1204 1209.

4. Quigley HA, West SK, Rodriguez J, Munoz B, Klein R, Snyder R.The prevalence of glaucoma in a population-based study of His-panic subjects. Arch Ophthalmol.2001;119:1819 1826.

5. Mangione CM, Gutierrez PR, Lowe G, Orav EJ, Seddon JM. Influ-

ence of age-related maculopathy on visual functioning and health-related quality of life. Am J Ophthalmol. 1999;128:4553.

6. West SK, Munoz B, Rubin GS, et al. Function and visual impairmentin a population-based study of older adults: The SEE Project.InvestOphthalmol Vis Sci. 1997;38:72 81.

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life assessments in patients with glaucoma.Trans Am OphthalmolSoc. 1996;94:919 1028.

11. Klein R, Moss SE, Klein BEK, Gutierrez P, Mangione CM. TheNEI-VFQ-25 in people with long-term type I diabetes mellitus.ArchOphthalmol.2001;119:733740.

12. Mangione CM, Lee PP, Pitts J, Gutierrez P, Berry S, Hays RD. Psycho-metric properties of the National Eye Institute visual function ques-tionnaire (NEI-VFQ). Arch Ophthalmol. 1998;116:14961504.

13. Broman AT, Munoz B, West SK, et al. Psychometric properties ofthe 25-item NEI-VFQ in a Hispanic population: Proyecto VER.Invest Ophthalmol Vis Sci.2001;42:606 613.

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TABLE8. Eye Disease Categories

% of Total Sample

No eye disease 85.6Cataract only 6.3Diabetic retinopathy Only 5.1Glaucoma only 1.4Cataract and DR 0.9Cataract and glaucoma 0.3Glaucoma and DR 0.3Cataract, Glaucoma, and DR 0.04

Total number with complete eye assessment, 4557

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