Effectiveness of the "living successfully with low vision" self-management program: Results from a randomized controlled trial in Singaporeans with low vision.

OBJECTIVE: To determine the effectiveness of the "Living Successfully with Low Vision" (LSLV) self-management program to improve patient-reported outcomes in Singaporeans. METHODS: In this randomized controlled trial, 165 participants with low vision (LV) were recruited and assigned to usual care (LV aid training only; N = 82) or LSLV program (N = 83). The LSLV program focuses on problem solving, coping mechanism and anticipation/preparation for future needs. The primary outcome was vision-related quality of life (VRQoL; measured using the Impact of Vision Impairment [IVI] questionnaire), while secondary outcomes included health-related quality of life; mental health; and self-efficacy, assessed at baseline, 2-weeks and 6-months post-intervention. Within- and between-group comparisons were conducted using paired t-tests and repeated measures analysis of covariance, respectively. RESULTS: A total of 128 individuals (77.6%) completed all assessments. At 2 weeks, LSLV participants alone experienced a significant within-group improvement in the mean IVI Emotional score (P = 0.05) but not at 6 months. No other within- or between-group effects were observed. CONCLUSION: While SM programs have shown promising results in the management of many chronic diseases, our findings suggest that the LVSM program was not an effective approach for LV rehabilitation in Singapore. PRACTICE IMPLICATION: Other evidence-based strategies to improve QoL in patients with LV may be warranted.

Differential Association of Generalized and Abdominal Obesity With Diabetic Retinopathy in Asian Patients With Type 2 Diabetes.

IMPORTANCE: The association between obesity and diabetic retinopathy (DR) is equivocal, possibly owing to the strong interrelation between generalized and abdominal obesity leading to a mutually confounding effect. To our knowledge, no study in Asia has investigated the independent associations of these 2 parameters with DR to date. OBJECTIVE: To investigate the associations of generalized (defined by body mass index [BMI], calculated as weight in kilograms divided by height in meters squared) and abdominal obesity (assessed by waist to hip ratio [WHR]) with DR in a clinical sample of Asian patients with type 2 diabetes mellitus. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional clinic-based study was conducted at the Singapore National Eye Centre, a tertiary eye care institution in Singapore, from December 2010 to September 2013. We recruited 498 patients with diabetes. After exclusion of participants with ungradable retinal images and type 1 diabetes, 420 patients (mean [SD] age, 57.8 [7.5] years; 32.1% women) were included in the analyses. EXPOSURES: Body mass index and WHR as waist/hip circumference (in centimeters). MAIN OUTCOMES AND MEASURES: The presence and severity of DR were graded from retinal images using the modified Airlie House Classification into none (n = 189), mild-moderate (Early Treatment Diabetic Retinopathy Study scale score, 20-41; n = 125), and severe DR (Early Treatment Diabetic Retinopathy Study scale score ≥53; n = 118). The associations of BMI and WHR with DR were assessed using multinomial logistic regression models adjusting for age, sex, traditional risk factors, and mutually for BMI and WHR. RESULTS: Among the total of 420 patients, the median (interquartile range) for BMI and WHR were 25.7 (5.7) and 0.94 (0.08), respectively. In multivariable models, BMI was inversely associated with mild-moderate and severe DR (odds ratio [OR], 0.90 [95% CI, 0.84-0.97] and OR, 0.92 [95% CI, 0.85-0.99] per 1-unit increase, respectively), while WHR was positively associated with mild-moderate and severe DR (OR, 3.49 [95% CI, 1.50-8.10] and OR, 2.68 [95% CI, 1.28-5.62] per 0.1-unit increase, respectively) in women (P for interaction = .006). No sex-specific associations were found between BMI and DR (P for interaction >.10). CONCLUSIONS AND RELEVANCE: In Asian patients with type 2 diabetes, a higher BMI appeared to confer a protective effect on DR, while higher WHR was associated with the presence and severity of DR in women. Our results may inform future clinical trials to determine whether WHR is a more clinically relevant risk marker than BMI for individuals with type 2 diabetes.

Dry Eye-Related Visual Blurring and Irritative Symptoms and Their Association with Depression and Anxiety in Eye Clinic Patients.

PURPOSE: Dry eye is a common condition known to have many systemic co-morbidities. We aim to report the frequency of depression and anxiety suspects in eye clinic patients and explore the association between dry eye signs and symptoms with depression and anxiety. MATERIALS AND METHODS: Adult outpatients were recruited from dry a public tertiary ophthalmology specialist center. Participants underwent socio-demographic and dry eye symptoms questionnaires, fluorescein dye tear break-up time (TBUT), fluorescein dye corneal staining and Schirmer's test. Rasch analysis was used to internally validate the Hospital Anxiety and Depression Scale (HADS) and the Center for Epidemiologic Studies Depression Scale (CES-D) and determine its psychometric properties. RESULTS: A total of 96 participants (mean age 54.5 ± 10.8; 64.1% women) were recruited. The mean score for the CES-D was 12.1 ± 9.8 with 28 participants (31.5%) having a score of above 16 (published threshold). The mean score for depression-associated questions in the HADS was 3.6 ± 3.6 with 13 participants (14.1%) having a score ≥8. The mean score for the anxiety-associated questions in the HADS was 5.3 ± 3.6 with 24 participants (26.1%) having score ≥8. There was a weak inverse correlation between Schirmer's test and CES-D scores. Elevated depression scores from the CES-D were significantly associated with visual blurring but not irritation, in dry eye patients with low TBUT. CONCLUSIONS: In conclusion, specific types of dry eye symptoms, particularly those with increased frequency of visual blurring were associated with symptoms of depression. The optical aberrations induced by dry eye, associated with tear instability, may predispose to depressive tendency.

Ethnic differences in undercorrected refractive error in Asians.

PURPOSE: To describe the ethnic variations in the prevalence and risk factors for undercorrected refractive error and its impact on vision-specific functioning (VF) in a multiethnic Asian population. METHODS: A total of 3353 Chinese, 3400 Indians, and 3280 Malays in Singapore participated in this population-based cross-sectional study. Distance presenting visual acuity (VA) was measured using a logarithm of the minimum angle of resolution number chart. Best-corrected VA was assessed using the same test protocol as presenting VA. Undercorrected refractive error was defined as an improvement of at least 0.2 logarithm of the minimum angle of resolution (two lines equivalent) in the best-corrected VA compared with the presenting VA in the better eye when presenting VA was less than 20/40 in the better eye. The VF-11 questionnaire measured participants' VF. Multivariate linear regression was performed to assess the impact of undercorrected refractive error on the overall VF score. RESULTS: Regardless of ethnicity, participants with undercorrected refractive error had a reduction in VF score compared to those with normal vision in both eyes. The overall prevalence of undercorrected refractive error was highest in Indians (25.1%), followed by Malays (22.2%) and Chinese (19.7%). Undercorrected refractive error was less common in spectacles or contact lenses wearers than in non-spectacle wearers or non-contact lenses wearers. Adults with mild to moderate refractive errors were most likely to have undercorrected refractive error (p < 0.001). In multivariate analysis, increasing age (p < 0.001), Indian race (p < 0.001), lower education level (p < 0.001) or poorer housing (p < 0.001), having refractive errors (p < 0.001), and not wearing optical corrections (p < 0.001) were significantly associated with increasing undercorrected refractive error. CONCLUSIONS: In Singapore, undercorrected refractive error is most prevalent in Indians and least prevalent in Chinese. The impact of undercorrected refractive error on VF was consistent across all three ethnicities. There may be higher barriers to visual correction among Malays or Indians compared with Chinese in Singapore.

Lack of awareness of common eye conditions in the community.

PURPOSE: Awareness of eye conditions aids health promotion activities and leads to better outcomes. We examined factors influencing the lack of awareness of common eye conditions in a population. METHODS: The Singapore Malay Eye Study examined 3280 (78.7% response) Malays aged 40-80 years. We included 2112 (64.4%) participants with at least one of five eye conditions: 1504 (71.2%) with cataract, 1013 (47.8%) with myopia, 270 (12.8%) with diabetic retinopathy, 181 (8.6%) with age-related macular degeneration and 150 (7.1%) with glaucoma. Lack of awareness was defined in the questionnaire as not answering "yes" to previously being told by a doctor of having the eye condition. RESULTS: Among 2112 participants, 83.2% were unaware of at least one of their eye conditions. After controlling for age, sex and socioeconomic factors, participants unaware of their eye condition were older (odds ratio, OR, 1.03, per 1 year, p < 0.001), had better visual acuity (OR 1.32, p = 0.04), lower education (OR 1.89, p < 0.001), poorer literacy (OR 1.44, p = 0.02), lower income (OR 1.73, p = 0.009), higher blood glucose (OR 1.08, per 1 mmol/L, p < 0.001), higher serum cholesterol (OR 1.20, per 1 mmol/L, p = 0.003), lower annual eye examination attendance (OR 2.08, p < 0.001) and were less likely to wear glasses (OR 2.90, p < 0.001) than those who were aware of their condition. CONCLUSIONS: In this community-based population, 80% of those with common eye conditions were unaware of their condition.

Critical issues in implementing low vision care in the Asia-Pacific region.

Two-thirds of the world's population with low vision resides in the Asia-Pacific region. Provision of comprehensive low vision services is important to improve vision-related quality of life (QoL) for people with this condition. This review outlines the critical issues and challenges facing the provision of low vision services in the Asia-Pacific region. The review offers possible strategies to tackle these issues and challenges facing service providers and policy makers in lieu of Vision 2020 strategies in this area. Pertinent findings from the global survey of low vision services and extensive ground work conducted in the region are used; in addition, a discussion on the availability of services, human resources and training, and funding and the future sustainability of low vision care will be covered. In summary, current issues and challenges facing the region are the lack of specific evidence-based data, access, appropriate equipment and facilities, human resources, funding, and sustainability. These issues are inextricably interlinked and thus cannot be addressed in isolation. The solutions proposed cover all areas of the VISION 2020 strategy that include service delivery, human resources, infrastructure and equipment, advocacy and partnership; and include provision of comprehensive care via vertical and horizontal integration; strengthening primary level care in the community; providing formal and informal training to enable task shifting and capacity building; and promoting strong government and private sector partnership to achieve long-term service financial sustainability.

The impact of cataract, cataract types, and cataract grades on vision-specific functioning using Rasch analysis.

PURPOSE: To determine the impact of cataracts and their types and grades on vision-specific functioning. DESIGN: Prospective population-based cross-sectional study. METHODS: The Singapore Indian Eye Study examined 3400 of 4497 (75.6% response rate) ethnic Indians 40 years of age and older living in Singapore. Three thousand one hundred sixty-eight (93.2%) fulfilled inclusion criteria with complete information for final analysis. Cataracts were assessed on slit-lamp examination and were graded according to the Lens Opacity Classification System III. Vision-specific functioning scores were explored with the Visual Function scale, validated using Rasch analysis. RESULTS: Two hundred sixty-nine (8.5%) and 740 (23.4%) of the study participants had unilateral and bilateral cataracts, respectively, and 329 (10.4%), 800 (25.2%), and 128 (4.1%) participants had nuclear, cortical, and posterior subcapsular (PSC) cataracts, respectively. In multivariate linear regression models, the presence of bilateral rather than unilateral cataract (ß = -0.12; 95% confidence interval, -0.20 to 0.00) was associated independently with poorer vision-specific functioning, even after adjusting for undercorrected refractive error (ß = -0.11; 95% confidence interval, -0.21 to 0.00). Bilateral nuclear, cortical, and PSC cataracts also were associated with poorer vision-specific functioning (ß = -0.31, -0.15, and -1.15, respectively), with combinations of them having even greater impact. Significantly poorer vision-specific functioning occurred at Lens Opacity Classification System grades 4 (nuclear opalescence), 5 (nuclear color), 3 (cortical), and 1 (PSC) or higher. CONCLUSIONS: People with bilateral but not unilateral cataracts experience difficulty with performing vision-specific daily activities independent of refractive error, with PSC cataracts and cataract combinations having the greatest impact. Cataract types cause poorer vision-specific functioning beginning at different severity grades.

Determinants of informed consent in a cataract surgery clinical trial: why patients participate.

OBJECTIVE: To identify the determinants of patients' decision-making for participation in a cataract surgery clinical trial in a tertiary care hospital. DESIGN: Prospective observational study. PARTICIPANTS: We interviewed by questionnaire 40 patients scheduled to have cataract surgery. METHODS: The data collected from patients included attitudes about informed consent, evaluation of the provision of information, and sociodemographic variables. RESULTS: Overall, 20 (50%) patients consented to enter the trial. All patients (n = 20;100%) in the consenting group expected positive implications compared to 6 (30%) in the nonconsenting group, who expected negative implications (p = 0.008). The majority of patients (90%) in the nonconsenting group felt that the degree of risk incurred by undergoing trial treatment was moderate to high. The perceived burden imposed on daily life by participating was seen by the nonconsenting group to be moderately higher in 11 patients (55%) compared to 3 patients (15%) in the consenting group (p = 0.026). Of the nonconsenting patients, 50% were dissatisfied with the attitudes of medical experiments as compared to 2% of those who did consent (p = 0.023). CONCLUSION: The major reasons for participation in a cataract surgery trial were (i) expected positive implications resulting from involvement; and (ii) satisfaction with the attitudes of medical experiments. Patients who refused to enter the trial felt that the degree of risk as well as the burden imposed on daily life by participating were high. Demographic variables did not have any impact on a patients' decisions to accept or decline entry into the trial.

Validation and reliability of the VF-14 questionnaire in a German population.

PURPOSE: To evaluate the validity, reliability, and measurement characteristics of the Visual Function 14 (VF-14) in a German sample using Rasch analysis. METHODS: This was a clinic-based, cross-sectional study with 184 patients with low vision recruited from an outpatient clinic at a German eye hospital. Participants underwent a clinical examination and completed the German VF-14 scale. The validity of the VF-14 scale was assessed using Rasch analysis. The main outcome measure was the overall functional score provided by the VF-14. RESULTS: After collapsing two response categories for items 13 and 14, the VF-14 scale satisfied fundamental criteria to achieve fit to the Rasch model, namely, ordered thresholds, the ability to distinguish between different strata of participant ability, absence of misfitting items, no evidence of unidimensionality, and no significant differential item functioning for key sociodemographic covariates. The VF-14 is able to discriminate between participants with different levels of vision impairment and across different cultural groups. CONCLUSIONS: The VF-14 is a valid, reliable, and unidimensional questionnaire for use in a German population. These findings contribute to the growing evidence base for second generation patient reported outcome measures in ophthalmology, and support the use of the German VF-14 in tertiary eye clinics in Germany to capture the impact of visual impairment on visual function from the patient's perspective and to inform low vision rehabilitation and interventions.

Literacy is an independent risk factor for vision impairment and poor visual functioning.

PURPOSE: People with limited literacy are at increased risks of chronic systemic conditions. The authors therefore investigated the independent contribution of limited literacy on visual impairment and visual function in a large eye survey in Singapore. METHODS: The authors undertook a population-based, cross-sectional study of Asian Malays (≥ 40 years old). Visual impairment was defined as logMAR (logarithm of minimal angle of resolution) visual acuity > 0.30 in the better-seeing eye. Information regarding reading and writing literacy levels and other independent variables, including sociodemographic measures (e.g., education, income), were obtained from a standardized interview. Visual functioning was assessed using a modified and validated version of the Vision-Specific Functioning Scale using Rasch analysis. RESULTS: Of the 3280 participants, 553 (16.9%) had inadequate reading literacy and 688 (21.0%) had inadequate writing literacy. In multivariate analysis, persons with inadequate reading literacy were more likely to have presenting visual impairment (odds ratio [OR] = 2.66; 95% confidence interval [CI] = 1.91 to 3.72; P < 0.001), best-corrected visual impairment (OR = 2.59; 95% CI = 1.70 to 3.96; P < 0.001), and poorer visual functioning (ß coefficient = 0.58; 95% CI = 1.57 to 3.02; P < 0.001), even controlling for education, income, and other patients' characteristics. Similar associations were found for inadequate writing literacy. CONCLUSIONS: Inadequate literacy is independently associated with visual impairment and poorer visual functioning. Interventions that address literacy may help to reduce socioeconomic disparities in visual impairment.

A global survey of low vision service provision.

PURPOSE: To conduct a global survey of low vision services to describe the needs, priorities, and barriers in provision and coverage. METHODS: Data were mainly derived from a survey and from some secondary sources. The survey was distributed to Vision 2020 contacts, government, and non-government organizations (NGOs) in 195 countries during 2006-2008. Themes in the survey were: epidemiology of low vision, policies on low vision, provision of services, human resources, barriers to service delivery, equipment availability, and monitoring and evaluation of service outcomes. Contradictory and/or incomplete data were returned for further clarification and verification. The Human Poverty Index was used to compare the findings from developed and developing countries. RESULTS: Service availability was established for 178/195 countries, with 115 having some low vision service. Approximately half the countries in the African and Western Pacific regions have no services. Few countries have >10 low vision health professionals per 10 million of population. In many of the countries NGOs were the main providers and funders. Funding and awareness were frequently cited as barriers to service access. Women, people with disabilities, and rural dwellers were less likely to access services. There were few reports of monitoring and evaluation into the quality and impact of services. CONCLUSION: This global survey provides the first consolidated baseline of low vision service provision. Where data are available, coverage of services is generally poor. Low vision health professional numbers are low. Services in over half of the world's countries are funded by NGOs, raising issues of sustainability.

The impact of the severity of vision loss on vision-specific functioning in a German outpatient population - an observational study.

BACKGROUND: To validate the German-translated VF-14, a vision-specific scale, and determine the relationship between the severity of vision impairment, ocular conditions, and visual functioning. METHODS: This was a clinic-based, cross-sectional study with 184 patients with low vision and 90 normal-sighted controls recruited from a German eye hospital. Participants underwent a clinical examination and completed the German VF-14 scale. The validity of the VF-14 scale was assessed using Rasch analysis. The main outcome measure was the visual functioning overall score. RESULTS: The participants' mean ± SD [standard deviation] age was 59.4 ± 21.8 years ,and there were more female (58.4%) than male participants. The main cause of vision loss was age-related macular degeneration [AMD] (n = 54, 19.7%). Rasch analysis substantiated the German VF-14 to be a valid scale to assess visual functioning in the sample. Visual functioning consistently declined with worsening vision. In adjusted-multivariate analysis models, compared to control participants, those with mild, or moderate/severe vision impairment recorded significantly poorer visual functioning scores (p < 0.05). The independent association was clinically significant for those with moderate/severe vision impairment. The main ocular conditions were also found to be independently associated with worse visual functioning, with clinical significance found for AMD, diabetic retinopathy, and other retinal diseases. CONCLUSIONS: Using a psychometrically valid German-translated VF-14, even mild vision impairment was independently associated with poor visual functioning. These findings reinforce the importance of early preventative and rehabilitative efforts to prevent longitudinal deterioration in vision loss.

The impact of vision impairment on vision-specific quality of life in Germany.

PURPOSE: To validate the German-translated Impact of Vision Impairment (IVI) questionnaire, a vision-specific quality of life (QoL) scale, and determine the relationship between the severity of vision impairment, ocular conditions, and VRQoL. METHODS: This cross-sectional study was clinic based, with 184 patients with low vision recruited from an outpatient clinic at a German eye hospital. Participants underwent a clinical examination and completed the German IVI scale. The validity of the IVI scale was assessed using Rasch analysis. The main outcome measure was the overall functional and emotional score provided by the IVI. RESULTS: Overall, there were more female (n = 111, 60.3%) than male participants. Participants' mean ± SD age and visual acuity in the better eye were 69.0 ± 15.5 years and. 0.41 ± 0.35 logMAR, respectively. The main cause of vision loss was age-related macular degeneration (n = 54, 29.3%). Rasch analysis demonstrated the validity of the German IVI to assess VRQoL through two subscales: vision-specific functioning and emotional well-being. In adjusted multivariate analysis models, those with mild or moderate/severe vision impairment reported significantly poorer vision-specific functioning (mean change, -6.5, P = 0.018 and -11.98, P < 0.001 for mild and moderate to severe VI, respectively) and emotional well-being (mean change, -2.35; P = 0.043 and -3.13, P = 0.004 for mild and moderate/severe VI respectively) compared with non-visually impaired patients. CONCLUSIONS: Using a psychometrically valid German IVI, even mild vision impairment was independently associated with poor VRQoL. These findings reinforce the importance of early preventative and rehabilitative efforts to prevent longitudinal deterioration in vision loss.

Identifying the critical success factors in the coverage of low vision services using the classification analysis and regression tree methodology.

PURPOSE: To identify the critical success factors (CSF) associated with coverage of low vision services. METHODS: Data were collected from a survey distributed to Vision 2020 contacts, government, and non-government organizations (NGOs) in 195 countries. The Classification and Regression Tree Analysis (CART) was used to identify the critical success factors of low vision service coverage. Independent variables were sourced from the survey: policies, epidemiology, provision of services, equipment and infrastructure, barriers to services, human resources, and monitoring and evaluation. Socioeconomic and demographic independent variables: health expenditure, population statistics, development status, and human resources in general, were sourced from the World Health Organization (WHO), World Bank, and the United Nations (UN). RESULTS: The findings identified that having >50% of children obtaining devices when prescribed (χ(2) = 44; P < 0.000), multidisciplinary care (χ(2) = 14.54; P = 0.002), >3 rehabilitation workers per 10 million of population (χ(2) = 4.50; P = 0.034), higher percentage of population urbanized (χ(2) = 14.54; P = 0.002), a level of private investment (χ(2) = 14.55; P = 0.015), and being fully funded by government (χ(2) = 6.02; P = 0.014), are critical success factors associated with coverage of low vision services. CONCLUSIONS: This study identified the most important predictors for countries with better low vision coverage. The CART is a useful and suitable methodology in survey research and is a novel way to simplify a complex global public health issue in eye care.