Clinical and Epidemiologic Research Vision-Related Quality of Life and Visual Function after for Various Vitreoretinal Disorders

Fumiki Okamoto, Yoshifumi Okamoto, Shinichi Fukuda, Takahiro Hiraoka, and Tetsuro Oshika

PURPOSE. To investigate vision-related quality of life (VR-QOL) have reported the influence of vitrectomy on VR-QOL in patients in patients undergoing vitrectomy for various vitreoretinal dis- with proliferative diabetic retinopathy (PDR), retinal detachment orders and to evaluate the relationship between VR-QOL and (RD), macular hole (MH), (ERM), and age- visual function. related (AMD).10–16 Such studies have dem- METHODS. The study included 100 normal control subjects and onstrated that vitrectomy can improve patients’ visual function as 299 patients with various vitreoretinal disorders including pro- well as VR-QOL. A comparison of changes in VR-QOL after sur- liferative diabetic retinopathy (PDR), diabetic macular edema gery among the various vitreoretinal diseases, however, has not (DME), branch retinal vein occlusion (BRVO), central retinal been conducted. In the present study, VR-QOL data from 100 vein occlusion (CRVO), macular hole (MH), epiretinal mem- normal subjects and 299 patients with various vitreoretinal disor- brane (ERM), and rhegmatogenous retinal detachment (RD). ders were assessed by the VFQ-25. The purpose of this study was The 25-item National Institute Visual Function Question- to compare VR-QOL among vitreoretinal disorders and to evaluate naire (VFQ-25) was answered by the patients with vitreoretinal the relationship between VR-QOL and visual function in each disorders before and 3 months after pars plana vitrectomy, as disorder. well as by the normal control subjects. Clinical data were collected, including , contrast sensitivity, and se- METHODS verity of metamorphopsia. RESULTS. Vitrectomy significantly improved the VFQ-25 com- We included 99 patients with proliferative diabetic retinopathy (PDR), 38 posite score in all vitreoretinal disorders. Preoperative VFQ-25 patients with diabetic macular edema (DME), 20 patients with branch composite scores in MH and ERM were significantly higher retinal vein occlusion (BRVO), 12 patients with central retinal vein occlu- than those in PDR, DME, and BRVO. Postoperative VFQ-25 sion (CRVO), 42 patients with macular hole (MH), 33 patients with composite scores were significantly higher in MH, ERM, and epiretinal membrane (ERM), and 55 patients with rhegmatogenous retinal RD than in PDR, DME, BRVO, and CRVO. A greater improve- detachment (RD), all of whom were underwent pars plana vitrectomy at ment in the VFQ-25 composite score was observed in ERM Tsukuba University Hospital between June 14, 2005, and April 20, 2007. than in DME. Multiple regression analysis revealed that changes One hundred volunteers served as normal control subjects. This research in contrast sensitivity had a significant correlation with was conducted according to the tenets of the Declaration of Helsinki, and changes in the VFQ-25 composite score in PDR and DME. written informed consent was obtained from each suitable participant. Changes in metamorphopsia were significantly associated with This study was approved by the Institutional Review Board at the Tsukuba changes in the VFQ-25 composite score in MH and ERM. University Hospital. Exclusion criteria included patients with a history of vitreoretinal surgery and ocular disorders except for mild refractive errors CONCLUSIONS. Vitrectomy significantly improved VR-QOL in var- and mild cataract. Patients who had undergone bilateral vitrectomy within ious vitreoretinal disorders. The largest improvement in VR- 3 months were excluded. QOL was observed in ERM and smallest improvement in DME. The logarithm of minimum angle of resolution best-corrected visual The visual function parameters associated with VR-QOL are acuity (logMAR BCVA), letter contrast sensitivity (CS), and severity of different depending on vitreoretinal disorders. (Invest Oph- metamorphopsia were obtained before surgery and at 3 months after thalmol Vis Sci. 2010;51:744–751) DOI:10.1167/iovs.09-3992 surgery. CS was measured by the CSV-1000LV chart (Vector Vision, Columbus, n , traditional objective clinical outcome mea- OH). This instrument uses letter optotypes, all of which are the same size Isures such as visual acuity are increasingly being comple- and of low spatial frequency (2.4 cyc/deg).17 There were eight contrast mented with assessment of patients’ perception of their visual levels (standard, 35.5%, 17.8%, 8.9%, 6.3%, 4.5%, 2.2%, and 1.1%), and function and quality of life. The National Eye Institute 25-Item each contrast level had three letters. The measurements were performed Visual Function Questionnaire (VFQ-25) is a vision-related quality at a 2.5-m distance under full spectacle correction. The mean luminance of life (VR-QOL) instrument designed to assess patients’ percep- 2 1 was 81 cd/m . The test results were recorded, not as the contrast thresh- tion of their visual function and QOL. The VFQ-25 has been used 18,19 2–16 old or CS, but as the number of 24 letters correctly identified. to track the outcome of many ocular diseases. Prior studies The severity of metamorphopsia was evaluated in the patients with MH and ERM (M-Charts; Inami Co., Tokyo, Japan). The M (metamorphop- sia)-Charts consist of 19 dotted lines with dot intervals ranging from 0.2° From the Department of Ophthalmology, Institute of Clinical to 2.0° of visual angle. If the straight line is replaced with a dotted line and Medicine, University of Tsukuba, Ibaraki, Japan. the dot interval is changed from fine to coarse, the distortion of the line Submitted for publication May 14, 2009; revised August 18, 2009; decreases with the increasing dot interval, until the dotted line appears accepted September 14, 2009. straight.20,21 At first, vertical straight lines (0°) were shown to the patient. Disclosure: F. Okamoto, None; Y. Okamoto, None; S. Fukuda, None; T. Hiraoka, None; T. Oshika, None If the patient recognized the line as straight, the metamorphopsia score Corresponding author: Fumiki Okamoto, Department of Ophthal- was 0. If the patient recognized the line as irregular or curved, then mology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Ten- subsequent pages of the M-Charts, in which the dot intervals of the dotted noudai, Tsukuba, Ibaraki, 305-8575 Japan; [email protected]. line change from fine to coarse, were shown one after another. When the

Investigative Ophthalmology & Visual Science, February 2010, Vol. 51, No. 2 744 Copyright © Association for Research in Vision and Ophthalmology

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TABLE 1. Background Data of Normal Controls and Patients with Vitreoretinal Disorders

NC PDR DME BRVO CRVO MH ERM RD

Eyes, n 100 99 38 20 12 42 33 55 Men/women 56/44 53/46 23/15 9/11 9/3 20/22 16/17 40/15 Age, y 61.2 Ϯ 9.9 57.7 Ϯ 12.9 62.7 Ϯ 9.0 64.1 Ϯ 9.1 62.4 Ϯ 11.3 64.3 Ϯ 9.6 67.0 Ϯ 8.4 52.3 Ϯ 13.2*

Data are expressed as the mean Ϯ SD. NC, normal control subjects. * Significantly different from the other groups (P Ͻ 0.05, Fisher PLSD).

patient recognized a dotted line as being straight, the visual angle that Visual Function Questionnaire (VFQ-25) separated the dots was considered to represent his or her metamorphop- The patients answered the VFQ-25 before surgery and 3 months after sia score for a vertical line. The M-Charts were rotated 90° and the same surgery. The preoperative VFQ-25 was completed 1 to 2 days before test was performed with the horizontal lines. The examinations were surgery. In the patients with RD, preoperative evaluation by VFQ-25 repeated three times for each subject, to evaluate reproducibility of the was not performed, because of the rapid nature of its onset. The results, and the mean was used for data analyses. The examination was research staff explained the questionnaire to the patients, gave instruc- performed at 30 cm and the refraction of the eye was corrected exactly for tions verbally, and provided assistance when required. The completed this distance. questionnaires were reviewed for missing data by the research staff. The indications for vitrectomy in the patients with PDR included Before surgery, all the missing items were filled out by the subjects recurrent or persistent nonclearing vitreous hemorrhage, traction or themselves. combined traction–rhegmatogenous retinal detachment, and adherent The VFQ-25 comprises 25 items that require the patient to assess posterior hyaloid causing excessive macular traction. DME was defined the levels of difficulty of particular visual symptoms or day-to-day by clinically significant macular edema according to the ETDRS guide- activities.1 Each item is assigned to one of the following 12 subscales: lines, diagnosed by slit lamp biomicroscopy, and a central foveal general health, general vision, ocular pain, near activities, distance thickness of Ն250 ␮m, as measured by optical coherence tomography activities, social functioning, mental health, role difficulties, depen- (OCT, Stratus OCT 3000; Carl Zeiss Ophthalmic Systems-Humphrey dency, driving, color vision, and peripheral vision. The subscales are 0 Division, Dublin, CA), and vitrectomy was indicated when Ն3 months to 100 points, where 100 indicates the highest possible function or had passed after at least one session of laser treatment and when minimal subjective impairment. The VFQ-25 composite score is calcu- logMAR BCVA in the affected eye was 0.2 or worse. The indication for lated as the unweighted average response to all items, excluding the vitrectomy in BRVO and CRVO included persistent nonclearing vitre- questions on general health.1 The VFQ-25 used in this study was a ous hemorrhage and/or cystoid macular edema. The indication for Japanese version, with modifications to suit the Japanese culture and vitrectomy in MH included stage II to IV full-thickness macular hole by lifestyle. The modified NEI VFQ-25 questionnaire has been assessed for means of slit lamp biomicroscopy with a 90-D fundus lens and OCT. reliability and validity, and it has been shown to accurately measure ERM was defined as a translucent or semitranslucent membrane with VR-QOL in Japanese individuals.22 macular thickening involving the center of the macula, with or without distortion and wrinkling of the inner retinal surface on biomicros- Statistical Analysis copy and OCT; vitrectomy was indicated if patients reported signif- icant metamorphopsia. The indications for vitrectomy in RD in- The mean scores and standard deviations were calculated for each cluded presence of causative horseshoe tears due to posterior VFQ-25 subscale and the composite score, in the patients with vitreo- vitreous detachment. retinal disorders and the normal control subjects. The Wilcoxon signed-ranks test was used to compare preoperative and postoperative results. The Mann-Whitney U test was performed to compare each Surgical Procedures subscale score and composite score between the patients with vitreo- All surgeries were performed by a single surgeon (FO) under sub- retinal disorders and the normal control subjects. Fisher’s protected Tenon local anesthesia. The crystalline lens was removed by phaco- least-significant difference (PLSD) was performed to compare subscale emulsification and intraocular lens implantation was performed when required, followed by 20-gauge, three-port pars plana vitrectomy or 25-gauge transconjunctival vitrectomy. With conventional contact lenses, posterior hyaloid separation and removal of the posterior vit- reous membrane were performed. Peripheral retinal examination with scleral depression was performed to search for a retinal tear or dialysis in all cases. In the patients with PDR, bimanual delamination, en bloc dissection, and segmentation techniques were used to remove prolif-

erative tissues, and when required, 20% sulfur hexafluoride (SF6) gas and/or silicone oil was injected. In the patients with ERM, the mem- brane was engaged and removed from the macula with a pick and intraocular forceps. In the patients with MH, the limiting membrane was peeled off with the aid of indocyanine green or triamcinolone

acetonide, followed by injection 20% SF6 gas. In the patients with RD, surgical procedures comprised release of vitreous traction around the breaks, internal drainage of the subretinal fluid, total gas–fluid ex-

change (20% SF6), and endolaser photocoagulation. In the patients with macular edema due to DME, BRVO, and CRVO, triamcinolone acetonide (4 mg in 0.1 mL) was injected into the vitreous cavity, and 20 mg in 0.5 mL triamcinolone acetonide was administered into the FIGURE 1. Preoperative and postoperative VFQ-25 composite scores sub-Tenon space of the superior temporal quadrant approximately 10 in the patients with vitreoretinal disorders and in the normal control mm posterior to the limbus, at the end of surgery. subjects. *P Ͻ 0.0001; †P Ͻ 0.01; ‡P Ͻ 0.05.

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TABLE 2. Preoperative VFQ-25 Composite Score and 12 Subscales in the Patients with Vitreoretinal Disorders and the Normal Control Subjects

VFQ-25 Scores NC PDR DME BRVO CRVO MH ERM

General health 57.8 (19.0) 39.1 (19.6)* 44.1 (19.7)† 40.0 (12.9)† 47.9 (17.4) 51.2 (17.4)‡ 55.3 (15.0) General vision 71.6 (14.8) 44.2 (21.2)* 46.3 (18.1)* 44.0 (21.1)* 51.7 (21.7)† 56.2 (17.2) 53.9 (17.7)* Ocular pain 80.6 (15.2) 75.1 (22.3) 73.4 (20.6) 73.1 (20.0) 78.1 (20.7) 82.1 (17.9) 76.1 (17.2) Near activities 81.8 (14.1) 44.2 (22.6)* 46.5 (21.1)* 44.4 (14.8)* 54.9 (22.6)* 59.5 (19.6)* 57.1 (17.3)* Distance activities 82.3 (13.5) 48.1 (22.8)* 51.5 (24.3)* 53.5 (18.5)* 56.3 (22.8)* 64.9 (21.3)* 60.7 (14.7)* Social functioning 90.9 (11.1) 59.5 (24.2)* 55.6 (27.7)* 61.3 (19.4)* 66.7 (19.5)* 78.0 (19.3)* 71.6 (19.3)* Mental health 87.0 (13.6) 43.6 (23.8)* 44.4 (25.8)* 50.9 (23.3)* 52.1 (29.0)* 69.3 (18.3)* 64.8 (16.6)* Role difficulties 84.9 (15.9) 52.9 (26.0)* 53.3 (29.3)* 48.8 (25.9)* 58.3 (24.6)* 72.6 (23.0)† 67.0 (17.3)* Dependency 95.5 (9.9) 53.3 (29.7)* 55.3 (31.7)* 62.5 (26.3)* 66.7 (23.3)* 83.1 (18.2)* 77.5 (17.7)* Driving 83.5 (12.3) 41.7 (34.2)* 45.4 (34.5)* 42.7 (28.4)* 57.5 (23.7)* 75.0 (19.2) 61.5 (23.0)* Color vision 94.0 (10.7) 69.5 (25.2)* 68.4 (23.7)* 70.0 (20.8)* 68.8 (24.1)* 86.6 (14.9)† 79.5 (14.6)* Peripheral vision 82.5 (18.6) 46.6 (23.3)* 45.4 (26.5)* 46.3 (18.6)* 54.2 (20.9)* 67.9 (20.9)† 67.4 (17.1)* Composite score 85.0 (9.1) 52.8 (19.0)* 53.0 (20.5)* 54.7 (15.5)* 60.4 (17.6)* 71.2 (14.3)* 66.9 (10.5)*

Data are expressed as the mean (SD). NC, normal control subjects. P, significantly different from the normal controls (Mann-Whitney’s U test). * P Ͻ 0.0001. † P Ͻ 0.01. ‡ P Ͻ 0.05.

scores, composite scores, and age among vitreoretinal disorders. The Vitrectomy significantly improved VFQ-25 composite score relationship between the preoperative and postoperative VFQ-25 com- in all vitreoretinal disorders except for RD in which preoper- posite scores and between the preoperative scores and changes in the ative VFQ-25 was not tested (Fig. 1). Change in the VFQ-25 VFQ-25 composite scores were examined with the Pearson’s correla- composite score was significantly higher in with vitreous tion coefficient. Before and after surgery, multiple regression analysis hemorrhage (15.0 Ϯ 11.4) than in eyes without vitreous hem- was performed to investigate the relationship between various explan- orrhage (7.8 Ϯ 10.7). The results of pre- and postoperative atory variables and VFQ-25 composite scores. Variables tested were VFQ-25 composite scores and 12 subscales in the patients with better-seeing BCVA, worse-seeing BCVA, better-seeing CS, worse-see- each vitreoretinal disorder and the normal control subjects are ing CS, and severity of metamorphopsia. The relationship between shown in Tables 2 and 3, respectively. The preoperative changes in the VFQ-25 composite score and changes in the explana- VFQ-25 composite score was significantly lower in the patients tory variables was also evaluated. All tests of association were consid- with vitreoretinal disorders than in the normal control sub- ered statistically significant at P Ͻ 0.05 (StatView, ver. 5.0; SAS Inc., Cary, NC). jects. In addition, the postoperative VFQ-25 composite scores remained significantly lower in the patients with disease than in the normal control subjects. RESULTS The box-and-whisker plots of the VFQ-25 scores in each Table 1 summarizes the background data of the normal control group are displayed in Figure 2. The preoperative VFQ-25 subjects and the patients with vitreoretinal disorders. The composite scores in the patients with MH and ERM were patients in the RD group were significantly younger than those significantly higher than those in the patients with PDR, DME, in the other groups (P Ͻ 0.05, Fisher’s PLSD). Among the 299 and BRVO. The postoperative VFQ-25 composite scores in the patients with vitreoretinal disorders, 24 were pseudophakic patients with the MH, ERM, and RD were significantly higher and 275 were phakic; 180 patients underwent combined cat- than those in the patients with PDR, DME, BRVO, and CRVO. aract surgery and vitrectomy. Fifty-two eyes had vitreous hem- Changes in the VFQ-25 composite scores in the patients orrhage (42 eyes with PDR, 7 eyes with BRVO, 2 eyes with RD, with ERM were significantly larger than those in the patients and 1 eye with RD). with DME.

TABLE 3. Postoperative VFQ-25 Composite Score and 12 Subscales in the Patients with Vitreoretinal Disorders and the Normal Control Subjects

VFQ-25 Scores NC PDR DME BRVO CRVO MH ERM RD

General health 57.8 (19.0) 39.0 (20.6)* 46.7 (16.6)† 43.8 (16.0)† 41.7 (16.3)† 53.6 (17.1) 55.3 (15.0) 54.2 (16.6) General vision 71.6 (14.8) 61.6 (17.6)* 53.2 (18.2)* 56.0 (19.0)† 60.0 (19.1)† 69.0 (14.1) 69.1 (11.3) 70.7 (14.9) Ocular pain 80.6 (15.2) 79.0 (19.6) 75.7 (20.3) 73.6 (19.0) 83.3 (13.4) 84.8 (16.0) 87.9 (11.9)‡ 82.4 (14.7) Near activities 81.8 (14.1) 55.6 (22.1)* 53.5 (21.0)* 63.3 (17.6)* 64.6 (19.2)† 70.2 (18.8)† 71.0 (18.2)† 75.3 (17.3)‡ Distance activities 82.3 (13.5) 58.8 (20.7)* 53.7 (23.6)* 63.8 (17.6)* 61.8 (17.2)† 72.2 (19.4)† 73.4 (16.0)† 75.6 (16.9)† Social functioning 90.9 (11.1) 74.6 (72.7)* 62.2 (25.6)* 70.0 (18.3)* 67.7 (8.4)* 82.7 (15.6)† 83.0 (9.3)* 88.2 (14.9) Mental health 87.0 (13.6) 59.1 (23.1)* 54.9 (26.2)* 57.5 (25.1)* 58.9 (25.2)* 76.6 (14.1)* 78.4 (13.1)† 77.5 (18.4)† Role difficulties 84.9 (15.9) 62.6 (23.9)* 57.9 (29.3)* 60.6 (25.4)* 62.5 (27.2)† 78.6 (21.8) 76.5 (20.0)‡ 78.5 (24.3) Dependency 95.5 (9.9) 66.3 (25.7)* 63.6 (31.8)* 73.2 (18.3)* 70.1 (22.9)* 85.7 (19.2)* 88.9 (11.0)* 87.2 (17.3)† Driving 83.5 (12.3) 54.5 (33.0)* 47.1 (35.3)* 50.0 (29.2)* 65.0 (16.5)† 78.6 (12.6) 76.0 (16.9) 75.5 (24.0) Color vision 94.0 (10.7) 72.2 (23.5)* 71.1 (27.0)* 76.3 (20.6)* 72.9 (16.7)* 85.7 (19.2)† 89.4 (12.5)‡ 94.0 (10.8) Peripheral vision 82.5 (18.6) 58.4 (21.2)* 54.6 (23.1)* 60.0 (20.5)* 60.4 (22.5)† 75.8 (19.3) 72.7 (17.0)† 72.2 (21.0)† Composite score 85.0 (9.1) 63.6 (17.5)* 59.0 (21.0)* 64.9 (15.0)* 66.4 (11.0)* 79.2 (13.0)‡ 78.5 (8.4)† 79.6 (14.2)‡

Data are expressed as the mean Ϯ SD. NC, normal control subjects. P, significantly different from the normal control (Mann-Whitney’s U test). * P Ͻ 0.0001. † P Ͻ 0.01. ‡ P Ͻ 0.05.

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FIGURE 2. Box-and-whisker plots with the top and bottom boundaries of the boxes indicating the 75th and 25th per- centiles, respectively. Whiskers above and below the box indicate the 90th and 10th percentiles, respectively. (A) Preop- erative VFQ-25 composite score in the patients with vitreoretinal disorders. (B) Postoperative VFQ-25 composite score. (C) Changes in VFQ-25 composite score. *P Ͻ 0.0001; †P Ͻ 0.01; ‡P Ͻ 0.05.

When scores of all the patients with vitreoretinal disor- tion parameters. The preoperative better-seeing BCVA exhib- ders were analyzed, the preoperative VFQ-25 composite ited significant correlation with the preoperative VFQ-25 com- score correlated significantly with postoperative VFQ-25 posite score in the patients with PDR and DME. In ERM, the composite score (r ϭ 0.799, P Ͻ 0.0001, Fig. 3A) and preoperative severity of metamorphopsia showed significant changes in the VFQ-25 composite score (r ϭ 0.549, P Ͻ correlation with the VFQ-25 composite score (Table 6). After 0.0001, Fig. 3B). The preoperative VFQ-25 composite score surgery, the better- and worse-seeing BCVAs exhibited signifi- correlated significantly with the postoperative VFQ-25 com- cant correlation with the postoperative VFQ-25 composite posite score in each group (Table 4). In addition, the pre- score in the patients with PDR. The postoperative severity of operative VFQ-25 composite score correlated significantly metamorphopsia showed significant correlation with the with changes in the VFQ-25 composite scores in the PDR, VFQ-25 composite score in MH and ERM. In the patients with CRVO, MH, and ERM groups (Table 4). RD, the postoperative VFQ-25 composite score correlated sig- Table 5 shows pre- and postoperative visual function in the patients with each disorder. Vitrectomy significantly nificantly with the postoperative worse-seeing CS (Table 7). In improved BCVA and CS in all the disease groups except MH and ERM, changes in the severity of metamorphopsia were CRVO. The surgery significantly improved metamorphopsia significantly relevant to changes in the VFQ-25 composite in MH and ERM. score, but changes in other variables were not, including BCVA Tables 6, 7, and 8 summarize the results of multiple regres- and CS. In addition, changes in the VFQ-25 composite score sion analysis on the relation between the VFQ-25 composite exhibited significant correlation with CS, not with BCVA in the score and several explanatory variables, including visual func- patients with PDR and DME (Table 8).

FIGURE 3. (A) The preoperative VFQ-25 score versus postoperative VFQ-25 composite score in all the patients. (B) Preoperative VFQ-25 composite score versus changes in VFQ-25 composite score in all pa- tients.

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TABLE 4. Relationship between Preoperative and Postoperative eases was rather high. As for patients with BRVO and CRVO VFQ-25 Composite Scores and Changes in the Scores who undergo vitrectomy, visual function, including visual acu- ity and visual field, is significantly decreased in many cases and Preoperative and Preoperative and thus it is not surprising that VR-QOL in these patients is also Postoperative VFQ- Changes in VFQ-25 25 Composite Score Composite Score decreased compared with patients with MH and ERM. As shown in the results, VR-QOL on each vitreoretinal disorder was significantly improved by vitrectomy. Previous studies have rP r P reported improvement in VR-QOL after ophthalmic surgery, such PDR 0.757 Ͻ0.0001* Ϫ0.374 Ͻ0.0001* as , photorefractive keratectomy, DME 0.753 Ͻ0.0001* Ϫ0.251 0.130 laser in situ keratomileusis and vitrectomy for PDR, ERM, MH, and 10,12,13,15,16,24–27 BRVO 0.795 Ͻ0.0001* Ϫ0.364 0.116 age-related macular degeneration. In this study, CRVO 0.687 Ͻ0.05* Ϫ0.783 Ͻ0.005* we compared the changes in the VFQ-25 composite scores MH 0.833 Ͻ0.0001* Ϫ0.418 Ͻ0.01* among vitreoretinal disorders and found a statistically significant ERM 0.611 Ͻ0.0001* Ϫ0.624 Ͻ0.0001* difference between ERM and DME. The preoperative VFQ-25 composite score in ERM was significantly lower than that in MH, * Significantly different (Pearson’s correlation coefficient). but increased to a level similar to that of MH after surgery. Gupta et al.28 used quality-adjusted-life-years (QALYs) methods to inves- DISCUSSION tigate VR-QOL in patients with ERM and reported that vitrectomy for ERM was a highly cost-effective procedure. The cost-effective- In our present study, pre- and postoperative VR-QOL was ness ratio of ERM surgery was higher than that of MH surgery. In assessed using VFQ-25 in the patients with various vitreoretinal MH, the preoperative VFQ-25 composite score was relatively disorders. The level of pre- and postoperative VR-QOL as well high, and thus surgery-induced improvement in VR-QOL re- as changes in VR-QOL showed a wide variation depending on mained rather small. In PDR, the VFQ-25 composite score gained the type of disease. The VFQ-25 used in this study was a considerable increases by surgery, 10.8 points, but a wide varia- Japanese version, with modifications to suit the Japanese. One tion was observed among patients. In DME and CRVO, we found item was changed to make it more appropriate to the Japanese that changes in the VFQ-25 composite score due to vitrectomy lifestyle and culture. The modified NEI VFQ-25 questionnaire were 5 points or less. Thus, effectiveness of vitrectomy in these has been assessed for reliability and validity, and it has been diseases may be relatively low. shown to accurately measure VR-QOL in Japanese individu- Postoperative VR-QOL, even after successful vitrectomy in als.22 The VFQ-25 composite scores in our results were similar each vitreoretinal disorder, did not reach the level of that in the to those in the study using the original NEI VFQ-25 in patients normal control subjects. This finding is consistent with the with MH, ERM, DME, and CRVO.9,13,15,23 When the preopera- results of previous case–control studies on VR-QOL in retinal tive VFQ-25 composite scores were compared among vitreo- disorders such as rhegmatogenous retinal detachment and pro- retinal diseases, we found that they were relatively high in MH liferative diabetic retinopathy.10,11 These results indicate the and ERM, whereas those in PDR, DME, and CRVO tended to be importance and need for further improvement in surgical tech- lower. In addition, postoperative VR-QOL was relatively high in niques and procedures, reviewing the timing of treatment, MH, ERM, and RD, but low in PDR, DME, BRVO, and CRVO. establishing means of early recognition and treatment, and Such polarization can be attributed to the characteristics of considering effective prophylactic measures. When the scores individual vitreoretinal disorders. PDR and DME usually affect were analyzed in the patients with vitreoretinal disorders alto- both eyes, and visual performance in these patients is often gether, preoperative VR-QOL was significantly associated with inferior to that in patients with other vitreoretinal diseases. postoperative VR-QOL as well as changes in VR-QOL. It is VR-QOL in PDR and DME was found to be poorer because suggested that surgical treatment should be considered as early VR-QOL was also significantly influenced by the visual perfor- as possible after a vitreoretinal disorder is recognized, so that mance of the fellow eyes. Hariprasad et al.23 demonstrated that vitrectomy can be performed to prevent further deterioration the VFQ-25 composite score of patients with DME was similar of the patient’s VR-QOL. to that of individuals with age-related macular degeneration, Multiple regression analysis revealed that the preoperative but lower than that of patients with type 1 diabetic retinopa- better-seeing BCVA correlated significantly with the preopera- thy, glaucoma, and cataracts. On the other hand, MH, ERM, and tive VFQ-25 composite score in the patients with PDR and RD are generally unilateral, and the visual performance of DME, in agreement with previous reports.10,29 Miskala et al.29 patients’ fellow eyes remained unaffected. For this reason, investigated VR-QOL in patients with subfoveal choroidal neo- preoperative VR-QOL in the patients with these unilateral dis- vascularization using VFQ-25, and demonstrated that changes

TABLE 5. Preoperative and Postoperative Visual Function in the Patients with Vitreoretinal Disorders

BCVA CS Metamorphopsia

Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative

PDR 1.37 Ϯ 0.75 0.53 Ϯ 0.62* 5.4 Ϯ 7.2 14.0 Ϯ 7.9* DME 0.76 Ϯ 0.49 0.55 Ϯ 0.51† 9.2 Ϯ 6.5 12.7 Ϯ 7.1* BRVO 1.25 Ϯ 0.63 0.38 Ϯ 0.38† 6.5 Ϯ 6.9 15.5 Ϯ 6.9† CRVO 1.23 Ϯ 0.59 1.14 Ϯ 0.47 2.7 Ϯ 6.1 3.9 Ϯ 6.5 MH 0.76 Ϯ 0.38 0.49 Ϯ 0.33* 14.3 Ϯ 7.1 18.5 Ϯ 4.3† 0.92 Ϯ 0.52 0.42 Ϯ 0.37* ERM 0.47 Ϯ 0.29 0.22 Ϯ 0.28* 15.0 Ϯ 5.2 19.0 Ϯ 5.2* 0.83 Ϯ 0.48 0.34 Ϯ 0.42* RD 0.55 Ϯ 0.65 0.15 Ϯ 0.24* 17.4 Ϯ 3.4 19.7 Ϯ 3.9†

Data are expressed as the mean Ϯ SD. P, significantly different from the preoperative values (Wilcoxon signed-ranks test). * P Ͻ 0.0001. † P Ͻ 0.01.

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TABLE 6. Results of Multiple Regression Analyses of Preoperative Composite Score and Explanatory Variables

BCVA CS

Better-Seeing Worse-Seeing Better-Seeing Worse-Seeing Metamorphopsia

PDR 0.012* 0.215 0.969 0.672 — DME 0.004* 0.594 0.187 0.943 — BRVO 0.552 0.490 0.234 0.535 — CRVO 0.244 0.729 0.664 0.702 — MH 0.308 0.598 0.061 0.430 0.106 ERM 0.362 0.340 0.165 0.705 0.049*

Objective variable is the preoperative VFQ-25 composite score; explanatory variables are preopera- tive better-seeing BCVA, preoperative worse-seeing BCVA, preoperative better-seeing letter CS, preoper- ative worse-seeing CS, and preoperative metamorphopsia. * Significant at P Ͻ 0.05.

in the overall and subscale scores were linearly related to By multiple regression analysis, we found that change in the changes in visual acuity of the better-seeing eye but are not severity of metamorphopsia was the single factor relevant to associated with changes in the worse-seeing eye. In ERM, VR-QOL in the patients with MH and ERM, while visual acuity preoperative severity of metamorphopsia showed significant and CS were not relevant factors. Until now, there has been no correlation with VFQ-25 composite score, whereas preopera- report that showed a significant relationship between in- tive visual acuity and CS showed no relationship with VFQ-25 creases in VR-QOL and improvement in visual function in composite score. This observation is not consistent with the patients with MH and ERM. Our results indicated that meta- result of a previous study by Ghazi-Nouri et al.,15 in which morphopsia plays a key role in the deterioration of visual VFQ-25 responses significantly correlated with visual acuity, functioning and VR-QOL in patients with MH and ERM. but not with CS and metamorphopsia in patients with ERM. As the results showed, changes in the VFQ-25 composite Such discrepancy between our and prior studies may be attrib- score exhibited significant correlation with CS, not with BCVA utable to the different methodology used to evaluate metamor- in the patients with PDR and DME. In several investigations of phopsia. In previous studies, the severity of metamorphopsia QOL outcomes after ocular surgery, only a weak or no corre- was estimated using the Amsler charts, whereas we used the lation was observed between increases in QOL and improve- M-Charts to quantitatively record the severity of metamorphop- ment in visual acuity.12,30 Visual acuity can be a poor predictor sia in this study. With the Amsler chart, precise and reproduc- of many aspects of visual function.31,32 CS has been shown to ible assessment of metamorphopsia is difficult because patients correlate with various aspects of activities requiring vision, have to self-describe the extent and degree of image distortion. including orientation, mobility, reading speed, and driving.33,34 On the other hand, the M-Charts can evaluate the degree of Carta et al.35 reported that CS was strongly associated with metamorphopsia quantitatively, since patients need simply to VR-QOL, even with adjustment for visual acuity among oph- indicate whether the dotted line is distorted. thalmic patients with chronic eye conditions such as age- Multiple regression analysis revealed that the postoperative related macular degeneration. In the patients who underwent better- and worse-seeing BCVAs correlated significantly with retinal detachment surgery, the postoperative VFQ-25 compos- the preoperative VFQ-25 composite score in the patients with ite score correlated significantly with CS and low-contrast vi- PDR. These results are consistent with those in a previous sual acuity, whereas there was no correlation between the report that assessed the relationship between postoperative VFQ-25 composite score and BCVA.11 In other studies, VFQ-25 BCVA and VFQ-25 score in the patients with PDR by simple responses correlated with CS as well as visual acuity in patients regression analysis.10 In PDR, the mean visual acuity in the with diabetes mellitus and age-related macular degenera- better-seeing eye deteriorated considerably, and the difference tion.2,36 It is noteworthy that improvement in CS was signifi- between the better- and worse-seeing eyes was small. This cantly associated with increases in VR-QOL in the patients with slight difference seems to be the reason that VFQ-25 score PDR and DME in our study. correlated with the visual function not only in the better-seeing Our study had several limitations. First, the sample size was eye but also in the worse-seeing eye. rather small, especially the number of patients with BRVO and

TABLE 7. Results of Multiple Regression Analysis on Postoperative VFQ-25 Composite Score and Explanatory Variables

BCVA CS

Better-Seeing Worse-Seeing Better-Seeing Worse-Seeing Metamorphopsia

PDR 0.033* 0.005* 0.824 0.311 — DME 0.008* 0.337 0.067 0.871 — BRVO 0.802 0.284 0.998 0.960 — CRVO 0.752 0.992 0.742 0.917 — MH 0.066 0.007* 0.903 0.437 0.005* ERM 0.128 0.097 0.412 0.250 0.048* RD 0.181 0.891 0.968 0.047* —

Objective variable is the postoperative VFQ-25 composite score; explanatory variables are postoper- ative better-seeing BCVA, postoperative worse-seeing BCVA, postoperative better-seeing letter CS, post- operative worse-seeing CS, and postoperative metamorphopsia. * Significant at P Ͻ 0.05.

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TABLE 8. Results of Multiple Regression Analysis on Changes in 9. Deramo VA, Cox TA, Syed AB, Lee PP, Fekrat S. Vision-related VFQ-25 Composite Score and Explanatory Variables quality of life in people with central retinal vein occlusion using the 25-item National Eye Institute Visual Function Questionnaire. Changes in Arch Ophthalmol. 2003;121:1297–1302. 10. Okamoto F, Okamoto Y, Fukuda S, Hiraoka T, Oshika T. Vision- BCVA CS Metamorphopsia related quality of life and visual function following vitrectomy for proliferative diabetic retinopathy. Am J Ophthalmol. 2008;145: PDR 0.273 0.003* — 1031–1036. DME 0.176 Ͻ0.0001* — 11. Okamoto F, Okamoto Y, Hiraoka T, Oshika T. Vision-related quality BRVO 0.716 0.056 — of life and visual function after retinal detachment surgery. Am J CRVO 0.609 0.288 — Ophthalmol. 2008;146:85–90. MH 0.260 0.145 0.013* 12. Hirneiss C, Neubauer AS, Gass CA, et al. Visual quality of life after ERM 0.993 0.328 0.009* macular hole surgery: outcome and predictive factors. Br J Oph- thalmol. 2007;91:481–484. Objective variable, changes in VFQ-25 composite score; explana- 13. Tranos PG, Ghazi-Nouri SM, Rubin GS, Adams ZC, Charteris DG. tory variables, changes in BCVA, changes in letter CS, and changes in Visual function and subjective perception of visual ability after metamorphopsia. macular hole surgery. Am J Ophthalmol. 2004;138:995–1002. * Significant at P Ͻ 0.05. 14. Tranos PG, Peter NM, Nath R, et al. Macular hole surgery without prone positioning. Eye. 2007;21:802–806. 15. Ghazi-Nouri SM, Tranos PG, Rubin GS, Adams ZC, Charteris DG. CRVO, and that may have influenced the VFQ-25 measure- Visual function and quality of life following vitrectomy and epireti- ments. Second, postoperative follow-up was short. We evalu- nal membrane peel surgery. Br J Ophthalmol. 2006;90:559–562. ated the patients at 3 months after surgery. It has been re- 16. Cahill MT, Stinnett SS, Banks AD, Freedman SF, Toth CA. Quality of ported that the VFQ-25 score in the patients with ERM life after macular translocation with 360 degrees peripheral reti- improved more at 1 year than at 3 months after surgery.15 nectomy for age-related macular degeneration. Ophthalmology. Thus, long-term investigations of patients after vitrectomy may 2005;112:144–151. yield different results regarding VR-QOL. Third, there may be 17. Pelli DG, Robson G, Wilkins AJ. The designed of a new letter chart some placebo effect in VFQ-25 measurements. The patients for measuring contrast sensitivity. Clin Vision Sci. 1988;2:187– 199. obviously recognized that they had surgery and may have 18. Maeda N, Sato S, Watanabe H, et al. Prediction of letter contrast answered postoperative VFQ-25 questions more positively sensitivity using videokeratographic indices. Am J Ophthalmol. with an expectation that they would benefit from the surgery. 2000;129:759–763. This effect cannot be avoided in designing the study, but it 19. Elliott DB, Bullimore MA, Bailey IL. Improving the reliability of the could account for some of the improvements in the VFQ-25 Pelli-Robson contrast sensitivity test. Clin Vision Sci. 1991;6:471– scores. Future studies with a larger sample size and longer 475. follow-up period, with some attempt to avoid the placebo 20. Matsumoto C, Arimura E, Okuyama S, Takada S, Hashimoto S, effect, will further facilitate our understanding of VR-QOL in Shimomura Y. Quantification of metamorphopsia in patients with patients undergoing surgery for vitreoretinal disorders. epiretinal membranes. Invest Ophthalmol Vis Sci. 2003;44:4012– 4016. 21. Arimura E, Matsumoto C, Okuyama S, Takada S, Hashimoto S, References Shimomura Y. Retinal contraction and metamorphopsia scores in eyes with idiopathic epiretinal membrane. Invest Ophthalmol Vis 1. Mangione CM, Lee PP, Gutierrez PR, Spitzer K, Berry S, Hays RD. Sci. 2005;46:2961–2966. National Eye Institute Visual Function Questionnaire Field Test 22. Suzkamo Y, Oshika T, Yuzawa M, et al. Psychometric properties of Investigators. Development of the 25-item National Eye Institute the 25-item National Eye Institute Visual Function Questionnaire Visual Function Questionnaire. Arch Ophthalmol. 2001;119:1050– (NEI VFQ-25), Japanese version. Health Qual Life Outcomes. 1058. 2005;3:65. 2. Cusick M, SanGiovanni JP, Chew EY, et al. Central visual function 23. Hariprasad SM, Mieler WF, Grassi M, Green JL, Jager RD, Miller L. and the NEI VFQ-25 near and distance activities subscale scores in Vision-related quality of life in patients with diabetic macular people with type 1 and 2 diabetes. Am J Ophthalmol. 2005;139: oedema. Br J Ophthalmol. 2008;92:89–92. 1042–1050. 24. Oshika T. Quantitative assessment of quality of vision (in Japa- 3. Berdeaux GH, Nordmann JP, Colin E, Arnould B. Vision-related nese). Nippon Ganka Gakkai Zasshi. 2004;108:770–807. quality of life in patients suffering from age-related macular degen- 25. Ishii K, Kabata T, Oshika T. The impact of cataract surgery on eration. Am J Ophthalmol. 2005;139:271–279. cognitive impairment and depressive mental status in elderly pa- 4. Cahill MT, Banks AD, Stinnett SS, Toth CA. Vision-related quality of tients. Am J Ophthalmol. 2008;146:404–409. life in patients with bilateral severe age-related macular degenera- 26. Belfort R, Campos M, Hoexter MQ, Belfort R Jr, Mari Jde J. The tion. Ophthalmology. 2005;112:152–158. impact of photorefractive excimer laser keratectomy (PRK) and 5. Kymes SM, Walline JJ, Zadnik K, Gordon MO. Collaborative Lon- laser in situ keratomileusis (LASIK) on visual quality and life in patients with ametropias (in Portuguese). Arq Bras Oftalmol. gitudinal Evaluation of Keratoconus Study Group: quality of life in 2008;71:83–89. keratoconus. Am J Ophthalmol. 2004;138:527–535. 27. Nichols JJ, Twa MD, Mitchell GL. Sensitivity of the National Eye 6. Hyman LG, Komaroff E, Heijl A, Bengtsson B, Leske MC. Early Institute Refractive Error Quality of Life instrument to refractive Manifest Trial Group: treatment and vision-related quality of life in surgery outcomes. J Cataract Refract Surg. 2005;31:2313– the early manifest glaucoma trial. Ophthalmology. 2005;112: 2318. 1505–1513. 28. Gupta OP, Brown GC, Brown MMA. Value-based medicine cost- 7. Schiffman RM, Walt JG, Jacobsen G, Doyle JJ, Lebovics G, Sumner utility analysis of idiopathic epiretinal membrane surgery. Am J W. Utility assessment among patients with dry eye disease. Oph- Ophthalmol. 2008;145:923–928. thalmology. 2003;110:1412–1419. 29. Miskala PH, Hawkins BS, Mangione CM, et al. and the Submacular 8. Bradley EA, Sloan JA, Novotny PJ, Garrity JA, Woog JJ, West SK. Surgery Trials Research Group. Responsiveness of the National Eye Evaluation of the National Eye Institute visual function question- Institute Visual Function Questionnaire to changes in visual acuity: naire in Graves’ ophthalmopathy. Ophthalmology. 2006;113: findings in patients with subfoveal choroidal : 1450–1454. SST Report No. 1. Arch Ophthalmol. 2003;121:531–539.

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30. Cassard SD, Patrick DL, Damiano AM, et al. Reproducibility and 34. Leat SJ, Woodhouse JM. Reading performance with low vision aids: responsiveness of the VF-14: an index of functional impairment relationship with contrast sensitivity. Ophthalmic Physiol Opt. in patients with cataracts. Arch Ophthalmol. 1995;113:1508– 1993;13:9–16. 1513. 35. Carta A, Braccio L, Belpoliti M, et al. Self-assessment of the quality 31. Owsley C, Sloane ME. Contrast sensitivity, acuity, and the per- of vision: association of questionnaire score with objective clinical ception of “real-world” targets. Br J Ophthalmol. 1987;71:791– tests. Curr Eye Res. 1998;17:506–511. 796. 36. Maguire M. Complications of Age-Related Macular Degeneration 32. Lennerstrand G, Ahlstrom CO. Contrast sensitivity in macular de- Prevention Trial Research Group. Baseline characteristics, the 25- generation and the relation to subjective visual impairment. Acta Item National Eye Institute Visual Functioning Questionnaire, and Ophthalmol (Copenh). 1989;67:225–233. their associations in the Complications of Age-Related Macular 33. Rubin GS, Roche KB, Prasada-Rao P, Fried LP. Visual impairment Degeneration Prevention Trial (CAPT). Ophthalmology. 2004;111: and disability in older adults. Optom Vis Sci. 1994;71:750–760. 1307–1316.

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