Quality of life study in ophthalmic practice

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BACKGROUND

The humanistic aim of the medical activity in any field is not the prolongation, and maintenance of the life rather it is providing the patient (if possible) with happier and more productive daily professional and household activities. In accordance with the principles of the evidence-based medicine, the main criteria for evaluating the efficiency of the treatment should be clinically significant results and outcomes of the treatment. At the same time, the investigation of the quality of life (QoL) reflects the degree of social adaptation of patients as the goal of the treatment and rehabilitation process. According to the generally accepted opinion, positive changes in therapy or in biomedical parameters indicate an improvement in the patient’s QoL. Even though this statement is true in many cases, in several clinical situations, when assessing the QoL of the patient, the results turn out to be unexpected, which determines the need to confirm this statement with special studies [1]. Currently, in a clinical practice, the results of a subjective assessment of the QoL reported by patients are of increasing interest and are actively used to record the impact of intervention or that of loss of the function. At the same time, the use of the psychometric characteristics such as significance, validity, and responsiveness to assess the QoL, is of great importance to ensure the validity of the data collected [2]. It is important to note the presence, both in the Russian Federation and other countries, of actively functioning organizations, that ensure the development, testing, and implementation of the QoL questionnaires in various fields of medical practice [3–5].

The current stage of development of ophthalmology is characterized by a significant expansion of the range of the diagnostic methods for studying the functional state of the visual analyzer. The introduction into the ophthalmological practice of instrumental methods for assessing the state of anterior and posterior segments of the eye, ocular blood flow, and morpho-functional aspects of individual structures of the eye, enabled to increase fundamentally the clinical efficiency of the diagnostic process, both from the standpoint of the primary detection of the pathological changes, and within the case follow-up and (or) evaluation of the results of therapeutic measures. At the same time, a significant increase in the diagnosis objectivity reduced the significance of assessing the patient’s subjective status. Meanwhile, it seems obvious that the leading factor for a patient is often not the presence of specific disorders of the visual system, but rather a change in a visual perception, spatial visual orientation, and, ultimately, improvement of the QoL [6–8].

This work aimed to perform a review of literature on proven methods for the QoL assessment in ophthalmic practice.

Analysis of “general” and “special” questionnaires for assessing the QoL of a patient in ophthalmic practice

The performed analysis indicates a large volume of questionnaires that assess the QoL of a patient with various ophthalmic diseases. It should be noted that the questionnaires reflect either general aspects of the patient’s professional and everyday life (“general” questionnaires) or are based on an assessment of the patient’s complaints in case of a certain ophthalmic disease or a group of the same type of diseases (“special” questionnaires). The main objective of this review was not so much to describe the questions and to interpret the results of questionnaires, but to assess the clinical efficiency of their use in the ophthalmological practice.

The most relevant general ophthalmological questionnaire is National Eye Institute Visual Function Questionnaire (NEI-VFQ) developed in the middle of the 1990s by the scientists from the National Eye Institute (USA). At the same time, there are various versions of this questionnaire, differing in the total number of questions (25, 39, or 51). This questionnaire was applied in practice in patients with an age-related macular degeneration [9–13], vitreoretinal conditions [14–17], myopia [18], cataract [19–21], glaucoma [22–24], keratoconus [25], dry eye syndrome [26], and several other ophthalmic diseases.

The practical implications of the NEI-VFQ should be emphasized. For example, a comparative assessment of patients with emmetropia, myopia, and stable stages of keratoconus did not reveal significant differences in the QoL, especially on a sociological subscale (“social functioning,” “role difficulties”). At the same time, the QoL significantly decreased in patients with progressive keratoconus (including those after corneal crosslinking). The authors conclude that, due to the high level of QoL in the patients with an early-stage keratoconus and a pronounced decrease after its progression without crosslinking, the current strategies of performing this procedure only after the diagnosis of progression is established, should be reconsidered [27].

The comparative assessment and analysis of the QoL and visual status in groups of patients with different types of mechanical eye injury [28], determined the expediency of clarifying the patient’s subjective assessment of his condition as early as at the stage of hospital admission, to be able to trace the changes in the QoL in future, responding to them in a timely manner, and making changes in the treatment approach during the post-traumatic period. The authors conclude that pain syndrome and psychological stress in patients after trauma require increased attention from the specialists, to determine the recovery strategy. An individual approach ensures the competent use of the questionnaires as tools for assessing the QoL.

It should also be noted that the NEI-VFQ is also used for research purposes. In this regard, the findings of an investigation [29], aimed to perform a comparative assessment of the QoL and macular pigment optical density (MPOD) in healthy volunteers, are of undoubtful practical interest. The responses to each question on the questionnaire were graded from low (no restriction) to high (very severe restriction) ranges. The results showed that, while the average response was “no restriction” for most (22/25) questions in the questionnaire, responses were slightly higher for two questions regarding the eye discomfort, and one question related to driving at night. MPOD levels were significantly higher in individuals who reported no discomfort in or around the eyes, than in those who reported mild discomfort. There was also a trend toward higher levels of MPOD in the individuals who reported that pain in or around their eyes never limited their activity, and in individuals who did not report problems in driving at night. The authors conclude that a higher level of MPOD reduces both the effects of “veiling” and uncomfortable glare among patients.

Along with the NEI-VFQ questionnaire, the “general” VF-14 (Visual Function) questionnaire is used in the ophthalmic practice [30, 31]. The practical application of this questionnaire enabled to develop an algorithm for choosing the method of surgical treatment in patients with cataracts and asteroid hyaloids, considering the state of the posterior hyaloid membrane [32].

There are much more developed and tested in clinical practice “special” questionnaires aimed at assessing the QoL in cataract [33–37], glaucoma [38–41], state after excimer laser surgery [42–44]. Along with this, the literature presents the questionnaires developed for patients with vitreoretinal conditions [45], allergic conjunctivitis [46, 47], computer vision syndrome [48–50], strabismus [51], amblyopia [52, 53], dry eye syndrome [54–57], diabetic retinopathy [58], age-related macular degeneration [59], endocrine ophthalmopathy [60], and several other eye diseases. A detailed description of each questionnaire was not included in the objectives of this article and is presented in the literature sources mentioned above.

General assessment of the investigation of patient’s QoL in ophthalmological practice

Assessing the state of the problem of investigating QoL in ophthalmological practice, the following three fundamental aspects should be highlighted. The first aspect is related to the presence of a sufficiently large amount of data, indicating the presence of a statistically significant correlations between the QoL and objective indicators of the visual system. At the same time, it is important to emphasize that this aspect is revealed both at the stage of the patient’s initial examination and in the process of treatment and rehabilitation measures. In this regard, the results of the study [19] should be emphasized especially, because it aimed to assess the QoL (according to the NEI-VFQ-25 questionnaire) in adult patients with a history of primary congenital glaucoma. The results obtained by the authors indicated that the lowest score belonged to the “mental health” scale, and the highest score belonged to the “color vision” scale. At the same time, a significant effect of the visual field defects was established in many subscales, including the “general health” and “general vision” ones. The mean visual field defect was statistically significantly associated with low scores in the “social functioning” and “peripheral vision” scales, which in total allowed the authors to formulate a conclusion about the presence of a relationship between visual field defects and many points in the subscales in the QoL assessment questionnaire applied.

In this direction (considering the general epidemiological situation), a study [61] should be noted, which assessed the impact of the quarantine during the COVID-19 pandemic on the QoL of patients with allergic conjunctivitis (according to a special Eye Allergy Patient Impact Questionnaire, EAPIQ). The results of this work showed that the symptoms of ocular allergy affect many functional and emotional aspects of the patient’s daily activities. The authors revealed that the severity of the impact of the allergic conjunctivitis on the patient’s QoL was moderate, which suggests a low significance of the influence of the quarantine factor during the COVID-19 pandemic, on the clinical and subjective manifestations of the allergic process.

Along with this, another study [62] determined the relationship of several visual indicators (visual acuity, contrast sensitivity, visual field) with the scales “social functioning,” “mental health,” and “role difficulties” (NEI-VFQ-25) of glaucoma patients. The study [11] determined a clear relationship between morphological aspects of retinal detachment (incomplete perifoveal detachment, incomplete parafoveal detachment, incomplete foveal detachment, complete foveal detachment, complete parafoveal detachment, complete perifoveal detachment), and QoL (according to the NEI-VFQ-25 questionnaire). The use of a special questionnaire (GQL-15) in glaucoma patients enabled (based on correlations with visual field and contrast sensitivity) to substantiate the optimal tactics of daily administration of ophthalmic medications [63].

The second aspect indicates the relationship between the examination of the patient’s QoL from the standpoint of clinical and economic analysis in ophthalmology [64]. Currently, the assessment of the relationship between the QoL and medical and economic indicators is widely used in treatment of patients with diseases that demand a constant use of drugs (glaucoma, age-related macular degeneration, ophthalmic oncology, and several others) [65–67]. At which point, it was shown that in patients with age-related macular degeneration treated with vascular endothelial growth factor inhibitors (anti-VEGF), the lowest QoL level (according to the special socio-economic questionnaire HRQoL) was noted before the treatment’s start, and the highest level was registered 6 months after the start of treatment (with a total follow-up of 12 months). At the same time, both the ophthalmic (best corrected distance visual acuity) and socio-psychological (income level, depression, social support) indicators were most associated with the QoL [68].

In this field, a study [22] should be especially noted, in which a comprehensive assessment of the cost (questionnaire EQ₅D) and of the QoL (questionnaire NEI-VFQ-25) was performed in glaucoma patients of urban and rural populations. The data obtained by the author indicate that non-compliance with the treatment regimen is a serious problem, especially in rural areas, where >50% of the patients may not return for follow-up visits. Although in most cases, medical therapy is the first line of treatment, the cost of maintaining it is up to 25% of the patient’s income. Glaucoma significantly reduces the performance of both questionnaires studied. According to the authors, the obtained results are of a great importance for healthcare planners seeking to determine cost effective and acceptable methods for both glaucoma detection and treatment, as this disease belongs to the leading causes of low vision and blindness.

The third aspect defines the relationship of tested questionnaires, as well as the principles for developing promising questionnaires. An analysis of the literature data indicates a rather good comparability of the results obtained when evaluating various QoL questionnaires in a patient with ophthalmic diseases, including the adaptation of an already tested questionnaire to a specific state language [69–71]. When developing prospective questionnaires, it should be considered that this process is based on several stages, with the ultimate aim of describing the condition that will be the subject of assessment as accurately and completely as possible, followed by a statistical confirmation of the significance, reliability, and sensitivity of the tool created, as well as of criteria for meaningful and constructive validity [72–74].

CONCLUSION

The relevance of QoL investigations in ophthalmology is due to the implementation of new humanistic approaches to medical practice. At the same time, the conducted studies indicate a high efficiency of including the assessment of the patient’s QoL in the complex of standard clinical and functional methods for examining the patient’s visual system.

ADDITIONAL INFORMATION

Author contributions. All authors confirm that their authorship complies with the international ICMJE criteria (all authors have made a significant contribution to the development of the concept, research, and preparation of the article, as well as read and approved the final version before its publication). I.G. Ovechkin developed the concept and design for the study, was involved in the final preparation of the article draft for publication; E.I. Kovrigina collected the data and wrote this article; M.E. Konovalov developed the concept and design for the study, was involved in the final preparation of the article draft for publication; V. Kumar developed the concept and design for the study, and collected the data.

Conflict of interest. The authors declare no obvious and potential conflicts of interest, related to the publication of the present article.

Funding. The funding is not stated.

About the authors

Igor G. Ovechkin

Academy of Postgraduate Education under the Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical Technologies of the Federal Medical Biological Agency

Author for correspondence.
Email: doctoro@mail.ru
ORCID iD: 0000-0003-3996-1012
SPIN-code: 8074-1879

MD, Dr. Sci (Med.), Professor

Russian Federation, 91, Volokolamskoe highway, Moscow, 125371,

Ekaterina I. Kovrigina

Ophthalmological Center of Karelia

Email: Dr.Kovrigina@eyes.mt

ophthalmologist

Russian Federation, Petrozavodsk

Michail E. Konovalov

Academy of Postgraduate Education under the Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical Technologies of the Federal Medical Biological Agency

Email: zenina@konovalov-eye-center.ru
ORCID iD: 0000-0002-3954-6233
SPIN-code: 2302-3493

Dr. Sci (Med).

Russian Federation, 91, Volokolamskoe highway, Moscow, 125371

Vinod Kumar

Peoples’ Friendship University of Russia

Email: Kumarvinod1955@gmail.com
ORCID iD: 0000-0002-5489-4607
SPIN-code: 9287-6007

Dr. Sci (Med).

Russian Federation, Moscow

References

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