Visual function in patients followed at a Veterans Affairs polytrauma network site: an electronic medical record review.

BACKGROUND: This observational study describes the "Polytrauma System of Care" used by the Veterans Health Administration to guide medical care and rehabilitation of injured military personnel serving in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) and reports the visual function of patients with polytrauma and/or traumatic brain injury (TBI) at the Hines, Illinois, Polytrauma Network Site (PNS). METHODS: A retrospective medical record review was performed for 103 patients with polytrauma seen at the Hines PNS from October 2005 through March 2008 and 88 patients with TBI seen in the Hines TBI Clinic from December 2007 through March 2008. RESULTS: Visual symptoms were self-reported by 76% of patients with polytrauma and 75% of the patients with TBI. Problems with reading (polytrauma 60% and TBI 50%) and accommodation (polytrauma 30% and TBI 47%) were frequently found on eye examinations. Spectacles were the treatment most frequently prescribed (polytrauma 62% and TBI 78%). CONCLUSIONS: It is important for optometrists to be aware of the high rates of self-reported symptoms and visual problems in military personnel returning from deployment to the wars in Iraq and Afghanistan. Post-traumatic stress disorder and depression may complicate optometric evaluation and management.

Measuring outcomes of vision rehabilitation with the Veterans Affairs Low Vision Visual Functioning Questionnaire.

PURPOSE: To evaluate the sensitivity to change, in patients who undergo vision rehabilitation, of the Veteran Affairs (VA) Low Vision Visual Functioning Questionnaire (LV VFQ-48), which was designed to measure the difficulty visually impaired persons have in performing daily activities and to evaluate vision rehabilitation outcomes. METHODS: Before and after rehabilitation, the VA LV VFQ-48 was administered by telephone interview to subjects from five sites in the VA and private sector. Visual acuity of these subjects ranged from near normal to total blindness. RESULTS: The VA LV VFQ exhibited significant differential item functioning (DIF) for 7 of 48 items (two mobility tasks, four reading tasks, and one distance-vision task). However, the DIF was small relative to baseline changes in item difficulty for all items. Therefore, the data were reanalyzed with the constraint that item difficulties do not change with rehabilitation, which assigns all changes to the person measure. Subjects in the inpatient Blind Rehabilitation Center (BRC) program showed the largest changes in person measures after vision rehabilitation (effect size = 1.9; t-test P < 0.0001). The subjects in the outpatient programs exhibited smaller changes in person measures after rehabilitation (effect size = 0.29; t-test P < 0.01). There was no significant change in person measures for the control group (test-retest before rehabilitation). CONCLUSIONS: In addition to being a valid and reliable measure of visual ability, the VA LV VFQ-48 is a sensitive measure of changes that occur in visual ability as a result of vision rehabilitation. Patients' self-reports of the difficulty they experience performing daily activities measured with this instrument can be used to compute a single number, the person measure that can serve as an outcome measure in clinical studies. The VA LV VFQ-48 can be used to compare programs that offer different levels of intervention and serve patients across the continuum of vision loss.

Use of Rasch person-item map in exploratory data analysis: a clinical perspective.

The National Institutes of Health (NIH) includes visual impairment in the 10 most prevalent causes of disability in America. As rehabilitation programs have the potential to restore independence and improve the quality of life for affected persons, NIH research priorities include evaluating their effectiveness. This paper demonstrates a clinical perspective on the use of the Rasch person-item map to evaluate the range and precision of a new vision function questionnaire in early analysis (prior to full sample). A self-report questionnaire was developed to measure the difficulty that persons with different levels of vision loss have performing daily activities. This 48-item Veterans Affairs Low-Vision Visual Functioning Questionnaire (VA LV VFQ-48) was administered to 117 low-vision patients. Preliminary analysis indicates that the questionnaire items are applicable to persons of differing abilities. The Rasch person-item map demonstrates that the field-test version of the VA LV VFQ-48 has good range and is well centered with respect to the person measure distribution. Construct validity and reliability are also demonstrated.

Is there a standard of care for eccentric viewing training?

A study was conducted to determine the current Department of Veterans Affairs (VA) standard of practice for eccentric viewing (EV) training. EV training is the process of teaching patients to realign the visual image away from a diseased foveal/macular region onto healthier retina. Optometrists and Visual Skills Instructors at all VA blind rehabilitation centers (BRCs) and VICTORS (vision impairment centers to optimize remaining sight) programs were asked to rate preference for EV prescription criteria, evaluation, and training techniques. Responses were received from 70% of BRCs and 67% of VICTORS. The respondents reported that all programs include EV training. The average minutes of training per patient varied from 20 minutes to nearly 24 hours, with instructors within a single center varying by as much as two orders of magnitude. Routinely, 82% of optometrists prescribe EV training, yet no consensus was found among these practitioners as to the criteria for selecting the best EV area. The results of this survey reveal an inconsistent standard of practice across VA centers and demonstrate the need for prospective studies of the efficacy, effectiveness, and cost-effectiveness of EV training.

Psychometric properties of the Veterans Affairs Low-Vision Visual Functioning Questionnaire.

PURPOSE: To describe psychometric properties of a self-report questionnaire, the Veterans Affairs (VA) Low-Vision Visual Functioning Questionnaire (LV VFQ-48), which was designed to measure the difficulty visually impaired persons have performing daily activities and to evaluate low-vision outcomes. METHODS: The VA LV VFQ-48 was administered by telephone interview to subjects with visual acuity ranging from near normal to total blindness at five sites in the VA and private sector. Rasch analysis with the Andrich rating scale model was applied to difficulty ratings from 367 subjects, to evaluate measurement properties of the instrument. RESULTS: High intercenter correlations for item measure estimates (intraclass correlation coefficient [ICC]=0.97) justified pooling the data from these sites. The person measure fit statistics (mean square residuals) confirm that the data fit the assumptions of the model. The item measure fit statistics indicate that responses to 19% of the items were confounded by factors other than visual ability. The separation reliabilities for pooled data (0.94 for persons and 0.98 for items) demonstrate that the estimated measures discriminate persons and items well along the visual ability dimension. ICCs for test-retest data (0.98 for items and 0.84 for persons) confirm temporal stability. Subjects used the rating categories in the same way at all five centers. Ratings of slight and moderate difficulty were used interchangeably, suggesting that the instrument could be modified to a 4-point scale including not difficult, slightly/moderately difficult, extremely difficult, and impossible. Fifty additional subjects were administered the questionnaire with a 4-point scale to confirm that the scale was used in the same way when there were four rather than five difficulty ratings. CONCLUSIONS: The VA LV VFQ-48 is valid and reliable and has the range and precision necessary to measure visual ability of low-vision patients with moderate to severe vision loss across diverse clinical settings.

Measuring low-vision rehabilitation outcomes with the NEI VFQ-25.

PURPOSE: To evaluate the sensitivity of the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) to change in visual abilities after low-vision rehabilitation in two different Veterans Administration (VA) low-vision programs METHODS: Seventy-seven legally blind veterans from the Blind Rehabilitation Center (BRC) at Hines VA Hospital and 51 partially sighted veterans from the Visual Impairment Center to Optimize Remaining Sight (VICTORS) program at the Chicago Health Care Network, West Side Division, were administered the NEI VFQ-25 plus supplement in interview format at admission and discharge. Instructions for administration were modified to have study participants answer all the questions as if they were wearing glasses or contact lenses or were using low-vision devices. Interval measures of person ability and item difficulty were estimated from the patients' responses to 34 of the 39 items on the VFQ-25 plus supplement before and after rehabilitation, by the polytomous rating scale measurement model of Wright and Masters. RESULTS: In VICTORS patients, item order by difficulty before rehabilitation agreed with item order for BRC patients. Visual ability scales are used similarly by different patients with different degrees of low vision. Based on prerehabilitation person measure distributions, VICTORS patients were less disabled, as would be predicted by visual acuity, than were BRC patients. After rehabilitation, estimated item difficulty for 4 of the 34 items decreased significantly in both BRC and VICTORS patients. CONCLUSIONS: The present study demonstrates that the NEI VFQ-25 plus supplement can be used to measure the effects of low-vision rehabilitation; however, only 7 of the 34 items tested are sensitive to change after rehabilitation. Targeted activities, such as reading ordinary print, small print, and street signs are easier to perform for graduates of both programs after rehabilitation. The patients' visual ability also shows improvement in both BRC and VICTORS. Improvement in visual ability is independent of change in difficulty of targeted items. Although this was not a controlled clinical trial, the decrease in difficulty of targeted items may reflect the use of low-vision aids and training to make tasks easier. The change in visual ability may reflect positive outcomes of rehabilitation or may be the consequence of patients' overestimates of their functional ability at the time of discharge.