Vision-Related Quality of Life Before and After Deep Anterior Lamellar Keratoplasty.

OBJECTIVES: To determine changes in the vision-related quality of life in patients undergoing deep anterior lamellar keratoplasty (DALK) by using the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25). METHODS: Thirty-five patients who were scheduled for DALK between March 1, 2013, and March 1, 2014 were asked to complete the NEI VFQ-25. NEI VFQ-25 was administered again at 6 months and at 1 year postoperatively. Data on patients' age, sex, preoperative diagnosis, preoperative and postoperative best-corrected visual acuity, and postoperative astigmatism were recorded. RESULTS: Successful DALK with the Anwar big bubble technique was achieved in 23 of 35 (65.7%) patients. The indications for surgery were keratoconus in 15 patients (62.2%), stromal corneal dystrophies in 4 (17%), and corneal scar in 4 (17%). The mean preoperative NEI VFQ-25 composite score (55.2±19.7) improved significantly (76.9±11.6) at 6 months after DALK and continued to improve (84.3±6.6) at 1 year postoperatively (Friedman test, P=0.001). All NEI VFQ-25 subscale item scores increased significantly after surgery. The patients' age was significantly correlated with the NEI VFQ-25 subscale score of mental health at 6 month and at 1 year postoperatively (r=0.92, P=0.008 and r=0.94, P=0.005, respectively). There was a negative relationship between postoperative astigmatism at 1 year and NEI VFQ-25 ocular pain, social functioning, peripheral vision, and mental health subscale scores (r=-0.76, P=-0.07; r=-0.53, P=0.2; r=-0.53, P=0.27; r=-0.80, P=0.05). CONCLUSION: Vision-related quality of life improved significantly after DALK and continued to improve after suture removal.

Comparison of perceptual eye positions among patients with different degrees of anisometropia.

The aim of this study is to compare the perceptual eye positions (PEPs) among patients with different degrees of anisometropia.A total of 157 patients were recruited into this retrospective study. A detailed ophthalmic examination was conducted on each patient. The degree of refractive errors in the presence of astigmatism was converted into the degree of spherical equivalent (SE). Patients were divided into 3 groups according to the interocular SE difference: severe anisometropia group with interocular SE difference ≥2.50D, mild anisometropia group with interocular SE difference ≥1.00D and <2.50D, and non-anisometropia group with interocular SE difference <1.00D. The vertical and horizontal PEP were measured by a computer-controlled perceptual examination evaluation system. The results obtained from the 3 groups were compared and analyzed.A total of 157 patients were enrolled including 32 patients in the severe anisometropia group, 37 patients in the mild anisometropia group, and 88 patients in the non-anisometropia group. The quartiles of vertical PEP pixels were as follows: 7.50 (5.00, 16.75) in the severe anisometropia group, 5.00 (2.00, 7.50) in the mild anisometropia group, and 5.00 (3.00, 9.00) in the non-anisometropia group, respectively. The vertical PEP pixel was much higher in the severe anisometropia group than that in the other two groups (P < .05). The quartiles of horizontal PEP pixels were as follows: 27.50 (10.75, 67.50) in the severe anisometropia group, 17.00 (7.00, 54.50) in the mild anisometropia group, and 21.50 (11.00, 60.75) in the non-anisometropia group. There were no statistically significant differences among the 3 groups (P > .05).There was an obvious deviation of vertical PEP in patients with anisometropia ≥2.50D, indicating that the instability of vertical PEP might be associated with the development of severe anisometropia.

Symptoms and Satisfaction of Patients in the Patient-Reported Outcomes With Laser In Situ Keratomileusis (PROWL) Studies.

IMPORTANCE: Patient-reported outcomes should be collected using validated questionnaires prior to and following laser in situ keratomileusis (LASIK) surgery. OBJECTIVE: To report the frequency of patient-reported visual symptoms, dry eye symptoms, satisfaction with vision, and satisfaction with LASIK surgery in the Patient-Reported Outcomes With LASIK (PROWL) studies. DESIGN, SETTING, AND PARTICIPANTS: The PROWL-1 and PROWL-2 studies were prospective, observational studies conducted from September 13, 2011, to June 27, 2014. The PROWL-1 study was a single-military center study of 262 active-duty Navy personnel 21 to 52 years of age. The PROWL-2 study was a study of 312 civilians 21 to 57 years of age conducted at 5 private practice and academic centers. The LASIK surgery and the postoperative care were performed based on the usual practice and clinical judgment at the site. Participants completed a self-administered, web-based questionnaire, preoperatively and postoperatively at 1 and 3 months (the PROWL-1 and -2 studies) and at 6 months (the PROWL-2 study). EXPOSURES: Participants underwent LASIK surgery for myopia, hyperopia, and/or astigmatism. MAIN OUTCOMES AND MEASURES: Visual symptoms (double images, glare, halos, and/or starbursts), dry eye symptoms, participant satisfaction (with vision and LASIK surgery), and clinical measures (visual acuity, refractive error, and slitlamp and posterior segment eye examination findings) were assessed preoperatively and at 1, 3, and 6 months postoperatively. RESULTS: A total of 262 participants were enrolled in the PROWL-1 study (mean [SD] age, 29.1 [6.1] years), and a total of 312 participants were enrolled in the PROWL-2 study (mean [SD] age, 31.5 [7.3] years). Visual symptoms and dissatisfaction with vision were common preoperatively. Overall, the prevalence of visual symptoms and dry eye symptoms decreased, although a substantial percentage of participants reported new visual symptoms after surgery (43% [95% CI, 31%-55%] from the PROWL-1 study and 46% [95% CI, 33%-58%] from the PROWL-2 study at 3 months). The percentages of participants in the PROWL-1 study with normal Ocular Surface Disease Index scores were 55% (95% CI, 48%-61%) at baseline, 66% (95% CI, 59%-72%) at 3 months, and 73% (95% CI, 67%-79%) at 6 months. The percentages of participants in the PROWL-2 study with normal Ocular Surface Disease Index scores were 44% (95% CI, 38%-50%) at baseline and 65% (95% CI, 59%-71%) at 3 months. Of those participants who had normal scores at baseline in both the PROWL-1 and -2 studies, about 28% (95% CI, 19%-37%) had mild, moderate, or severe dry eye symptoms at 3 months. While most participants were satisfied, the rates of dissatisfaction with vision ranged from 1% (95% CI, 0%-4%) to 4% (95% CI, 2%-7%), and the rates of dissatisfaction with surgery ranged from 1% (95% CI, 0%-4%) to 2% (95% CI, 1%-5%). CONCLUSIONS AND RELEVANCE: The systematic administration of a questionnaire to patients who have undergone LASIK surgery is a new approach to assess symptoms and satisfaction. Our findings support the need for adequate counseling about the possibility of developing new symptoms after LASIK surgery.

Quality of life for amblyopic children and their parents.

AIM: To highlight the changes in the quality of life in patients with anisometric, refractive, strabic and mixed amblyopia and to assess the psychosocial implication for their family. MATERIAL AND METHODS: Prospective observational transversal study of 44 ambulatory pa- tients (88 eyes) treated in the Ophthalmology Clinic of Iasi "Sf. Spiridon" Hospital and Iasi Stereopsis Ophthalmology Clinic. Clinical parameters: visual acuity, objective refraction (autorefractometry), optical correction type, stage of binocular vision, ocular motility, strabic deviation. The patients or their attendants accepted to fill out a questionnaire comprising 46 items pertaining to 9 domains to assess patient (or parents) adherence to treatment and issues related to quality of life. RESULTS: Mean age of study patients was 8.19 ± 2.92 years (range 4-16 years) and age at first diagnosis was: 3.90 ± 2.15 years. Moderate and severe amblyopia in the right eye was present in 47.72% of cases and in the left eye in 43.18%. Right eye uncorrected visual acuity was 0.45 ± 0.31 and corrected 0.63 ± 0.31 (p < 0.0001). Left eye uncorrected visual acuity was 0.49 ± 0.33 and corrected was 0.69 ± 0.32 (p < 0.0001). No statistically significant difference between the right and left eye were found. A 46-item questionnaire focused on child health, visual acuity, binocular vision, time to occlusion or penalization, child emotions/activity, family and society integration was used. CONCLUSIONS: The first presentation to the ophthalmologist was at age 3.9091 ± 2.1597 years (range 3 months-7 years). Health promotion and education is important to determine parents to seek help from an ophthalmologist not later than age 3. The main symptoms that led the parents to seek eye care were: strabic deviation--45.45%, difficulty seeing the blackboard--11.36%, and difficulty in seeing closer--20.45%. Quality life questionnaires detect life or school problems of children with amblyopia and educate parents. In 15.91% of parents they did not knew that before treatment the child had poor school results. This study represents the first step in Romanian ophthalmologists concern for socio-professional integration of children with amblyopia, because as we know some jobs require healthy eyes and for those who do not receive appropriate treatment their dream will be denied.

Correction of refractive errors in rhesus macaques (Macaca mulatta) involved in visual research.

Macaques are the most common animal model for studies in vision research, and due to their high value as research subjects, often continue to participate in studies well into old age. As is true in humans, visual acuity in macaques is susceptible to refractive errors. Here we report a case study in which an aged macaque demonstrated clear impairment in visual acuity according to performance on a demanding behavioral task. Refraction demonstrated bilateral myopia that significantly affected behavioral and visual tasks. Using corrective lenses, we were able to restore visual acuity. After correction of myopia, the macaque's performance on behavioral tasks was comparable to that of a healthy control. We screened 20 other male macaques to assess the incidence of refractive errors and ocular pathologies in a larger population. Hyperopia was the most frequent ametropia but was mild in all cases. A second macaque had mild myopia and astigmatism in one eye. There were no other pathologies observed on ocular examination. We developed a simple behavioral task that visual research laboratories could use to test visual acuity in macaques. The test was reliable and easily learned by the animals in 1 d. This case study stresses the importance of screening macaques involved in visual science for refractive errors and ocular pathologies to ensure the quality of research; we also provide simple methodology for screening visual acuity in these animals.

On the origin and status of the "El Greco fallacy".

The oddly elongated forms painted by the Spanish Renaissance artist El Greco are popularly but incorrectly attributed to astigmatism. The particular reason this explanation fails has long offered a deep lesson for perceptual psychology, even motivating recent research. However, the details and historical origins of this lesson--often called the "El Greco fallacy"--have been obscured over many retellings, leading to an incomplete and even inaccurate understanding of its provenance and status. This note corrects the record, which is richer, subtler, and more interesting than recent accounts would suggest.

The association between schoolchildren intelligence and refractive error.

PURPOSE: The relationship between refractory errors and intelligence and the importance of genetic, regional and environmental factors in such associations, were investigated in a group of school children. SUBJECTS AND METHODS: One hundred and thirty-seven students (34.3% boys and 65.7% girls) from two primary schools were enrolled in the study. Cycloplegic refraction was performed and a spherical equivalent (SE) > or = 0.5D were determined as hyperopia; <-0.5D myopia and <1 cyl D astigmatism. Demographic factors, parent's education level, teacher based assessment of school performance and average score were also evaluated. RESULTS: Seventy-eight (56.9%) of subjects showed a form of refractory error; 27%, 3% and 2.9% were myope, hyperope or astigmat, respectively, whereas 12.4% of them had both myopia and astigmatism and 10.2% showed hyperopia and astigmatism; 43.1% were normal. CONCLUSIONS: Although our data revealed no distinction of average score between normal group and myopia, hyperopia, astigmatism or hyperopia-astigmatism, there is a statistically significant difference between normal group and those who had both myopia and astigmatism in which the later had a lower mediocre. Our results is somehow in contrast with other parallel studies demonstrating that positive connection between school performance and myopia can be explained by the geographical or racial discrepancies as well as subjects involved in the study and divergent set of cut off limits.

Visual and non-visual factors associated with patient satisfaction and quality of life in LASIK.

PURPOSE: The aim of this study was to determine how laser in situ keratomileusis (LASIK) affects quality of life (QOL) and to identify factors that may affect satisfaction after LASIK. METHODS: A total of 104 patients with a mean age of 29±6, treated with LASIK for myopia and astigmatism, were enrolled in a prospective study. High (90%) and low (10%) contrast visual acuity (CVA) were measured under photopic and scotopic conditions before surgery and at 3 months later. A multidimensional QOL scale (Institute for Eye Research multidimensional QOL scale), which assesses psychological characteristics, personality traits, cosmesis, frequency, and tolerance to disturbing visual and ocular symptoms, and overall satisfaction with vision correction, was also used. Paired rank tests were used to compare preoperative and postoperative vision and QOL scores. Correlations and a multiple linear regression were used to describe the relationship between CVA, QOL, and satisfaction after LASIK. RESULTS: Significant postoperative changes included increased satisfaction following LASIK (P<0.001), reduced frequency of visual and ocular symptoms (P<0.001), and change in psychological characteristics (P=0.033). The change in satisfaction with LASIK can be predicted by a combination of preoperative satisfaction, postoperative frequency of disturbing visual and ocular symptoms, postoperative mean spherical equivalent, and postoperative scotopic high CVA (R (2)=0.725, P<0.05). CONCLUSIONS: Satisfaction with LASIK is related to visual function, preoperative expectations, psychological characteristics, and uncorrected CVA achieved. An increased sense of subjective well-being, adaptability, and self-efficacy was evident after LASIK. Patients reported a more optimistic attitude to life and increase perceived QOL after surgery.

Adapting to blur produced by ocular high-order aberrations.

The perceived focus of an image can be strongly biased by prior adaptation to a blurred or sharpened image. We examined whether these adaptation effects can occur for the natural patterns of retinal image blur produced by high-order aberrations (HOAs) in the optics of the eye. Focus judgments were measured for 4 subjects to estimate in a forced choice procedure (sharp/blurred) their neutral point after adaptation to different levels of blur produced by scaled increases or decreases in their HOAs. The optical blur was simulated by convolution of the PSFs from the 4 different HOA patterns, with Zernike coefficients (excluding tilt, defocus, and astigmatism) multiplied by a factor between 0 (diffraction limited) and 2 (double amount of natural blur). Observers viewed the images through an Adaptive Optics system that corrected their aberrations and made settings under neutral adaptation to a gray field or after adapting to 5 different blur levels. All subjects adapted to changes in the level of blur imposed by HOA regardless of which observer's HOA was used to generate the stimuli, with the perceived neutral point proportional to the amount of blur in the adapting image.

[Quality of life after Lasik: part I. Validation of the French translation of the NEI-RQL-42 scale]. / Qualité de vie après Lasik : partie I. Validation de la traduction française de l'échelle NEI-RQL-42.

INTRODUCTION: The objective of this study was to bring some validation elements to a French adaptation of an American refraction-related quality of life scale, as applied to a population of Lasik patients. METHODS: The NEI-RQL-42 scale was developed in 2003 in the United States. It comprises 42 questions and 13 scores exploring quality of vision, functional symptoms, influence of refraction on daily activities and psychological impact. The authors propose here a French adaptation and elements for its validation (internal consistency, discriminating validity and external validity). These were assessed through an observational cross-sectional study, performed in one center on all patients consecutively treated with Lasik between January and March 2008. RESULTS: The study sample (307 patients) has the expected characteristics of Lasik-treated patients. The French adaptation of the NEI-RQL-42 has a good internal consistency with Cronbach's coefficients greater or equal to 0.7 for 10 scores out of 12. The discriminating validity of the scale was shown though the reference groups techniques: quality of life is generally lower in severe hyperopes compared with non-severe myopes. The scale's external validity is confirmed by the comparison of its results to those of a satisfaction questionnaire that was simultaneously sent to patients. CONCLUSION: The results obtained are favorable arguments for the validity of the proposed French adaptation of the NEI-RQL-42. This is the first scale available in French to assess refraction-related quality of life.

[Patient satisfaction after posterior lamellar keratoplasty (DSAEK)]. / Patientenzufriedenheit nach posteriorer lamellärer Keratoplastik (DSAEK).

BACKGROUND: The advantages of posterior lamellar keratoplasty (DSAEK) compared to conventional full thickness keratoplasty are faster visual rehabilitation, little change in astigmatism and the absence of suture-associated complications. The current study evaluated the satisfaction of the first 15 patients who underwent DSAEK at our clinic. MATERIALS AND METHODS: Evaluation of patient satisfaction was conducted via a telephone survey and by means of a written patient questionnaire. The patients were asked to answer questions on a scale from 1 (very bad) to 10 (very good) about their overall satisfaction with this procedure, their satisfaction with the achieved postoperative visual acuity, their satisfaction with the progress of the healing process and the extent of the perceived burden. The patients were also asked whether they would opt again for the operation. Pre- and postoperative visual acuity, IOP, topographic astigmatism and corneal pachymetry were analysed. RESULTS: 15 eyes of 15 patients were analysed (12 women and 3 men). Average age at the time of operation was 75 +/- 7 years. Visual acuity increased and corneal thickness decreased primarily within the first three months. During that time there was an increase in overall patient satisfaction which finally reached 6.9 +/- 1.8 on the scale. Postoperative visual acuity was awarded with 7.2 +/- 2.0, progress of the healing process with 7.4 +/- 2.3. The procedure was not perceived as a big burden (8.0 +/- 1.9) and most patients would have decided again for the operation (8.2 +/- 2.0). There was no pre- and postoperative difference in IOP and corneal astigmatism. CONCLUSIONS: Like in our group patients with diseases of the corneal endothelium are of higher age and therefore benefit from a fast restitution of visual acuity and a low burden of operation. DSAEK represents a secure and practical procedure to rehabilitate elderly patients with diseases of the corneal endothelium.

The effect of dioptric blur on reading performance.

Little is known about the systematic impact of blur on reading performance. The purpose of this study was to quantify the effect of dioptric blur on reading performance in a group of normally sighted young adults. We measured monocular reading performance and visual acuity for 19 observers with normal vision, for five levels of optical blur (no-blur, 0.5, 1, 2, and 3D). Dioptric blur was induced using convex trial lenses placed in front of the testing eye, with the pupil dilated and in the presence of a 3mm artificial pupil. Reading performance was assessed using eight versions of the MNREAD Acuity Chart. For each level of dioptric blur, observers read aloud sentences on one of these charts, from large to small print. Reading time for each sentence and the number of errors made were recorded and converted to reading speed in words per minute. Visual acuity was measured using 4-orientation Landolt C stimuli. For all levels of dioptric blur, reading speed increased with print size up to a certain print size and then remained constant at the maximum reading speed. By fitting nonlinear mixed-effects models, we found that the maximum reading speed was minimally affected by blur up to 2D, but was approximately 23% slower for 3D of blur. When the amount of blur increased from 0 (no-blur) to 3D, the threshold print size (print size corresponded to 80% of the maximum reading speed) increased from 0.01 to 0.88 logMAR, reading acuity worsened from -0.16 to 0.58 logMAR, and visual acuity worsened from -0.19 to 0.64 logMAR. The similar rates of change with blur for threshold print size, reading acuity and visual acuity implicates that visual acuity is a good predictor of threshold print size and reading acuity. Like visual acuity, reading performance is susceptible to the degrading effect of optical blur. For increasing amount of blur, larger print sizes are required to attain the maximum reading speed.

Amblyopia in astigmatic children: patterns of deficits.

Neural changes that result from disruption of normal visual experience during development are termed amblyopia. To characterize visual deficits specific to astigmatism-related amblyopia, we compared best-corrected visual performance in 330 astigmatic and 475 non-astigmatic kindergarten through 6th grade children. Astigmatism was associated with deficits in letter, grating and vernier acuity, high and middle spatial frequency contrast sensitivity, and stereoacuity. Although grating acuity, vernier acuity, and contrast sensitivity were reduced across stimulus orientation, astigmats demonstrated orientation-dependent deficits (meridional amblyopia) only for grating acuity. Astigmatic children are at risk for deficits across a range of visual functions.

Effect of blur adaptation on blur sensitivity in myopes.

Although blur adaptation in myopia has been investigated, knowledge regarding its effect on blur sensitivity remains unknown. In the present study, changes in three blur thresholds (i.e., noticeable, bothersome, and non-resolvable blur) were assessed monocularly after 1h of blur adaptation in myopes. A Badal optical system was used to present either an isolated 20/50 Snellen E or 20/50 lines of text, with the full text field used in the latter condition for all blur judgments. Eight visually normal adult myopes were tested with paralyzed accommodation. All subjects exhibited blur adaptation, with a significant improvement in group mean visual acuity of -0.16 LogMAR. There was a consistent and concurrent significant decrease of 0.15-0.19 D in all blur thresholds for the isolated 20/50 E. However, there was no significant effect of blur adaptation on blur thresholds for the 20/50 text, with large intersubject variability evident. The enhanced blur sensitivity for the isolated E target may in part be attributed to the increased visual resolution following blur adaptation. Differences found in the blur thresholds for the two targets may be related to a variety of neuroperceptual phenomena, in particular lateral masking.

Functional outcomes and patient satisfaction after laser in situ keratomileusis for correction of myopia.

PURPOSE: To determine subjective patient satisfaction and self-perceived quality of vision after laser in situ keratomileusis (LASIK) to correct myopia and myopic astigmatism. SETTING: Department of Ophthalmology, Academic Hospital Maastricht, Maastricht, The Netherlands. METHODS: A validated questionnaire consisting of 66 items was self-administered by 142 consecutive patients. Seven scales covering a specific aspect of quality of vision were formulated. Aspects included global satisfaction, quality of uncorrected and corrected vision, quality of night vision, glare, daytime driving, and night driving. Main outcome measures were responses to individual questions and scale scores, and correlations with clinical parameters including refractive outcome, uncorrected visual acuity, best corrected visual acuity, ablation depth, and scotopic pupil-optical zone disparity were obtained. RESULTS: The mean score for the overall satisfaction was 4.1 +/- 0.71 (SD) (scale 0 to 5.0). A total of 92.2% of patients were satisfied or very satisfied with their surgery, 93.6% considered their main goal of surgery achieved, and 92.3% would choose to have LASIK surgery again. Satisfaction with uncorrected vision was 3.03 +/- 0.71. The mean score for glare was 3.0 +/- 0.9. At night, glare from lights was believed to be more important than before surgery by 47.2%. Glare from oncoming car headlights after surgery was reported by 58.4% and was believed to be more bothersome for night driving than before surgery by 52.8%. Night driving was rated more difficult than before surgery by 39.4%, whereas 59.3% had less difficulty driving at night. There was a significant correlation between the uncorrected vision score and the postoperative spherical equivalent (r = 0.245) and postoperative astigmatism (r = 0.265). There was no correlation between the glare or night vision scores and the degree of correction, the amount of ablation depth, or the disparity between the scotopic pupil and the optical zone. CONCLUSIONS: Self-perceived uncorrected vision after LASIK surgery for the correction of myopia and myopic astigmatism appears to be very good and is related to the postoperative residual error. Although the majority of patients postoperatively experienced glare, particularly with driving at night, this was not related to the pupil-optical zone disparity or degree of correction.

Grating visual acuity testing as a means of psychophysical assessment of progressive addition lenses.

Progressive addition lenses (PAL's) are subject to objectionable astigmatism due to the aspheric nature of their anterior surfaces. Optico-physical assessment of PAL's is commonly undertaken but these measures should be related to the psychophysical responses of patients whilst wearing PAL's. A technique previously used for the psychophysical assessment of contact lenses and spectacle lenses is adapted and demonstrated for the measurement of grating visual acuity (VA) through the aspheric portion of PAL's. The apparatus encompasses an astronomical telescope with magnifying power of unity designed to stabilize accommodation. This paper considers the astigmatism present with three different PAL designs along a horizontal section cutting orthogonally through the umbilical line of each lens. VA was measured, using high contrast vertical and horizontal gratings, along the same horizontal sections of the PAL's studied. A reduction in VA was noted with an increase in the angle of eccentricity from the umbilical line.

Detection and recognition of visual targets.

To aid the development of detection-based interpretations of visual resolution, we evaluated theorems that (1) relate observers' performance in detection of a single target to that in 1-of-m signal detection and (2) predict recognition performance from measured performance at 1-of-m detection. These theorems require that the sensory effects of the stimuli be continuous and that the m signals be equally detectable and mutually orthogonal. To evaluate the theorems, we tested observers in simple detection, 1-of-m detection, and recognition of Landolt C targets and compared predicted and observed performance. Predictions of 1-of-m detection performance from that for simple detection and predictions of recognition from the 1-of-m receiver operating characteristic (ROC) were both accurate to within 0.03 in P(A). In addition, predictions of recognition based on the 1-of-m ROC predicted from simple detection were generally accurate. Thus, under restricted experimental conditions, recognition is determined completely by that for simple detection.