Vision-related Quality of Life After Cataract Surgery in West Africa

doi:10.21203/rs.3.rs-1675926/v1

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Research Article

Vision-related Quality of Life After Cataract Surgery in West Africa

https://doi.org/10.21203/rs.3.rs-1675926/v1

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posted 23 May, 2022

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AIMS

To study the vision related quality of life (VRQoL) before and after a mass cataract surgery campaign in a low-income country and to describe the impact of cataract surgery on quality of life (QOL).

METHODS

All the patients who had cataract surgery in Bobo-Dioulasso (Burkina Faso) during a campaign for the prevention blindness were examined. VRQoL was assessed using a modified version of the WHO/PBD VF20. The questionnaire was carried out before and three months after the surgery. A QOL related to vision index (QOL-RVI) was calculated from the scores obtained.

RESULTS

A total of 305 patients (56.1% male) underwent cataract extraction. Mean age was 61.97 ± 14.39 years. The majority of eyes (88.70%) had preoperatively poor visual acuity (CDVA<20/200). Three months after surgeries, good visual outcomes (VA ≥20/60) were achieved in 38.35% of eyes without correction and 68.7% with correction. At this time, QOL-RVI had improved postoperatively in 90.2% of patients, had not changed in 3.1% and was worse in 6.7%. Significant differences were detected (Wilcoxon test p <0.05) for all items tested before and after surgeries. Correlations for the patients after operations showed that there was a significant relation between a global estimated QOL-RVI and the UCVA previous to the surgery (ρ -0.196 p=0.014), regarding the same index and the BCVA after the procedures (ρ -0.35 p=0.00018).

CONCLUSIONS

Cataract surgery increases the quality of life of patients living in low-income countries such as Burkina Faso and the improvement correlates with the recovery of the visual acuity.

vision related quality of life

cataract surgery

blindness

West Africa

It is estimated that 237.1 million people (80% uncertainty interval 101.5 million to 399.0 million) worldwide suffer from moderate or severe visual impairment due to eye disease or uncorrected refractive error.[1] Of these, 38.5 million (13.2 million to 70.9 million) are blind (visual acuity worse than 3/60). Uncorrected refractive errors are the leading cause of visual impairment (53.9%) followed by cataracts (24.1%), age related macular degeneration (3,7%), glaucoma (1.9%), diabetic retinopathy (1.3%). The growth and ageing of the world’s population are the main factors for the increase in the number of blind and visually impaired.[2]

The modern concept of health suggests that the effectiveness of eye care and initiatives for the prevention of blindness should go beyond traditional clinical data collection and assessment. Clinical measures such as VA (visual acuity) give us an assessment of vision loss, but they do not fully characterize visual deficits faced by a disabled person in their daily activities. Therefore, the WHO recommends the use of methods to characterize visual function and vision-related quality of life (QOL) as a supplement to clinical evaluation.

As a result, the study of the assessment of visual function and QOL related to vision has been grown in interest, which has led to the development of instruments in the form of questionnaires, aiming to measure patients’ perception of the impact of a disease and its treatment.[3]

The assessment of the impact on QOL generated by visual deficits caused by cataract is only possible if certain objective parameters for evaluating its progress, the indication for surgery and improvement are recorded.

Visual Health is a major factor in the QOL and is closely related to the individual's independence and their interaction with the environment. The questionnaires on QOL and visual function have proved to be a valid tool to fully characterize the visual difficulties faced by a visually impaired person in their daily activities.[4–6]

Visual impairment has negative effects on QOL and a significant impact on daily life including social activities and emotional condition. Studies in different populations have shown that visual impairment is significantly associated with a decrease in QOL measured by the different questionnaires.[7, 8]

The purpose of cataract surgery is to improve visual acuity and visual function and it is assumed that this implies an improvement in the QOL.[9]

The World Health Organization (WHO) developed in 1994 a generic measure of QOL called World Health Organization QOL (WHO / QOL).[10]

This article reports findings on visual acuity and QOL outcomes in an African population of a low-income country, Burkina Faso. We report the results in terms of impact on QOL caused by cataracts and cataract surgery, obtained when using a vision-specific QOL questionnaire based on the WHO / QOL and adapted to consider local culture and environment. There are no studies regarding QOL after cataract surgery in Burkina Faso in the literature.

Study design

The present study is an analytic prospective study including a single cohort (before-after study) which involved a sample of population of all ages operated for cataract in one or both eyes in the context of a mass cataract surgery campaign for the prevention of blindness.

Studied population

305 patients were included. All of them underwent extracapsular cataract extraction with intraocular lens implantation during the campaign that the nongovernmental organizations, Stop Blindness and Vision Without Borders, conducted. Surgeries were performed in a district Hospital in Bobo-Dioulasso (Burkina Faso).

Cases eligible for inclusion had corrected distance visual acuity (CDVA) < 20/80 (0.6 Log MAR) in the best eye due to cataract. They were excluded if they had any other ophthalmic disease thought to be the main cause of blindness. There was no limitation in age. Cases were recruited by qualified local staff in the Bobo-Dioulasso area before the arrival of the surgical team. All patients had to be able to understand and respond to the questionnaire.

Research Ethics Approval.

The tenets of Declaration of Helsinki were followed, and informed consent about the surgical procedures and the participation in the study was obtained from each patient before the first interview and the surgery. The local institution in charge of approving sanitary actions and health studies (Le Direction Générale de la Santé du Burkina Faso) authorized the campaign and the clinical research.

Questionnaire: variables for the study and methodology of the interviews

The questionnaire was based on the “Quality of Life and Vision Function Questionnaire (WHO/PBD-VFQ-20)” (Table1) which is a quantitative structured questionnaire including twenty closed questions.

Qualified local people collaborated in the adaptation of the questionnaire. It was translated into French, the official language of Burkina Faso, and in an unwritten form into various local dialects. The method used was the standard procedure recommended by the WHO: initially, making a first translation, including forward and backward translation, then a discussion group was formed to address the differences and finally, the chosen response factors were evaluated via visual analog scales after selecting 20 patients for testing. These patients performed the test on the day of visual inspection and again the following day. The validity and reliability of this method were evaluated by standard psychometric methods, including the acceptability of the questions, internal consistency, reliability of the test, internal analysis and analysis against external criteria as well as the use of specific thresholds.[11]

The modified WHO/PBD-VFQ-20 -adapted to Burkinabe population- that was used for the present study is shown in Table 1. The excluded items were question 3 (there are not many stairs in Bobo-Dioulasso), question 6 (not many patients have shelves), 9 and 13 (as it was difficult to explain), 17 (duplicated in question 7), 18–20 (social difficulties in expression of feelings). We included 4 new questions, 13 (role limitation), 14 and 15 (far vision), and 16 (dependence).

Table 1

WHO/PBD-VFQ20 questionnaire versus the adaptive questionnaire applied in this study.
WHO/PBD-VFQ20	ADAPTATIVE QUESTIONNAIERE
1- Overall, how would you rate your eyesight using both eyes – with glasses or contact lenses if you wear them?	1- Overall, how would you rate your eyesight?
2-How much pain or discomfort do you have in your eyes (e.g. burning,itching, aching)?	2-How much pain or discomfort do you have in your eyes (e.g. burning, itching, aching)?
3-Because of your eyesight, how much difficulty do you have in going down steps or stairs?	Excluded
4- How much difficulty do you have in noticing obstacles while you are walking alone (e.g. animals or vehicles)?	3- How much difficulty do you have in noticing obstacles while you are walking alone (e.g. animals or vehicles)?
5-How much difficulty do you have in seeing because of glare from bright lights?	4- How much difficulty do you have in seeing because of glare from bright lights?
6-Because of your eyesight, how much difficulty do you have in searching for something on a crowed shelf?	Excluded
7- How much difficulty do you have in seeing differences in colours?	5- How much difficulty do you have in seeing differences in colours?
8 Because of your eyesight, how much difficulty do you have in recognizing the face of a person standing near you?	6-Because of your eyesight, how much difficulty do you have in recognizing the face of a person standing near you?
9-How much difficulty do you have in seeing the level in a container when pouring?	Excluded
10- Because of your eyesight, how much difficulty do you have in going to activities outside of the house (e.g. sporting events, shopping, religious events)?	7- Because of your eyesight, how much difficulty do you have in going to activities outside of the house (e.g. weddings, funeral and baptize)
11- Because of your eyesight, how much difficulty do you have in recognizing people you know from a distance of 20 metres?	8- Because of your eyesight, how much difficulty do you have in recognizing people you know from a far distance?
12- How much difficulty do you have in seeing close objects (e.g.making out differences in coins or notes, reading newsprint)?	9- How much difficulty do you have in seeing close objects (e.g. coins or rice cleaning)?
13- How much difficulty do you have in seeing irregularities in the path when walking (e.g. potholes)?	Excluded
14- How much difficulty do you have in seeing when coming inside after being in bright sunlight?	10- How much difficulty do you have in seeing when coming inside after being in bright sunlight?
15- How much difficulty do you have in doing activities that require you to see well close up (e.g. sewing, using hand tools)?	11- How much difficulty do you have in doing activities that require you to see well close up (e.g. sewing, using hand tools)?
16- Because of your eyesight, how much difficulty do you have in carrying out your usual work?	12- Because of your eyesight, how much difficulty do you have in carrying out your usual work?
New question	13- How much difficulty do you have in doing the domestic work?
New question	14- How much difficulty do you have in seeing television?
New question	15- How much difficulty do you have in seeing at night time?
17- Because of your eyesight, how often have you been hesitant to participate in social functions?	Excluded
New question	16- Because of your eyesight, do you need help from other people?
18- Because of your eyesight, how often have you found that you are ashamed or embarrassed?	Excluded
19- Because of your eyesight, how often have you felt that you are a burden on others?	Excluded
20- Because of your eyesight, how often do you worry that you may lose your remaining eyesight?	Excluded

Patients were interviewed individually by local investigators and the questionnaire was carried out before and three months after surgeries, asking about the patient’s perception of their vision and well-being. The quality of life and how it changes with cataract surgery was assessed using a questionnaire with closed questions with three possible answers ("good-bad-average" or "yes-no-a little bit”). The reason for giving only three responses was to simplify the options and facilitate the completion of the questionnaire. Rating scales with fewer response categories are likely to be more functional.[12] The assessment was done in this way: if the question was not applicable it was not taken into account for the scoring but it was registered as “not applicable”, value 1 for a negative value (No or bad), value 2 for an intermediate value (average or a little bit) and 3 for a positive (yes or good).

Variables for the study

A quality of life related to vision index (QOL-RVI) was calculated from the scores obtained. For each item this index was defined as the number of patients who responded “3” –good- divided by the total amount of patients and multiplied by 100.

For each patient the QOL-RVI was the sum of the results in all questions divided by the number of responses. On receipt of this index for each patient and at each time (preoperative and at 3 months) a bivariate analysis was done correlating this index with different variables involved throughout the study so any "risk factors" could be detected to get higher or lower QOL depending on the outcome of such correlations.

The QOL-RVI for each patient was later correlated with age, sex, UCVA and BCVA and the values of visual acuity were recorded on a decimal scale, later being transformed into log MAR for mathematical and statistical analysis.

Finally, a global QOL-RVI was estimated for the procedure (cataract surgery) as the arithmetical mean of the QOL-RVI for each item (expressed as a percentage) and the same for each patient (expressed as a numerical value).

Data were tabulated using a spreadsheet (Microsoft Excel, Windows XP Professional, Microsoft ™). Statistical analysis was performed using the Sigma Plot 11.0 for Windows (SYSTAT Software Inc.):

- Descriptive statistics of continuous variables for the description of the samples, descriptive statistics for categorical variables, comparison tests of means or medians (t-test or Mann-Whitney test) after applying Kolmogorov-Smirnov test on the samples and Wilcoxon test. Statistical significance was considered for comparisons when p values were under 0.05 (p < 0.05). Bivariate analysis for studying the correlation between pairs of variables the Spearman coefficient was used.

A total of 305 patients (56.1% male) underwent cataract extraction in at least one eye, 10 of these with bilateral surgery. The mean age was 61.97 ± 14.39 years. The right eye was operated in 47.30% of cases. Of the total number of patients, 196 (64%) came back 3 months after the surgery for the follow up and QOL evaluation. We recorded more than 22 different ethnic groups, with a majority of Mossi (32%) and Bobo (13%). 78% of the patients were illiterate and 61% of them had a monthly income less than 15,000 Fcfas (32$).

Visual acuity outcomes

Table 3 shows the number of cases, mean values, standard deviations and standard errors calculated before and three months after surgery for UDVA and CDVA. The majority of eyes had poor visual acuity (CDVA < 20/200, log MAR: 1.0) preoperatively (88.70%) with a mean VA of log MAR 2.17 ± 0.70 (20/2000). Three months after cataract surgery, best-corrected visual acuity increased to 0.52 ± 0.44 logMAR. Good outcomes (VA ≥ 20/60) were achieved in 38.35% of eyes without correction and 68.7% with correction. Poor outcomes (VA < 20/200) were found in 9.16% of the cases with correction.[13]

Quality of life related to vision outcomes.

Quality of life scores improved postoperatively in 90.2% of patients, did not change in 3.1% and were worse in 6.7%.

Regarding QOL-RVI for each item, significant differences were detected (Wilcoxon test p < 0.05) for all items tested when comparing the results before and after surgeries. In all cases, the result could be considered better at 3 months with two exceptions: question 2, patients had more pain after surgery and question 4, they had brighter light glare after surgery. The questionnaire scores improved in all domains after surgery in 1.42 times.

Table 2 shows the QOL-RVI for each of the 16 items in the questionnaire before surgery and after surgery at 3 months. Figure 1 shows graphically the rates pre-surgery and post-surgery at 3 months for the 196 patients who completed the survey. The mean preoperative global QOL-RVI was 1.73 (±0.37) and at the 3rd month after surgery it was 2.47(±0.31). Expressed as a percentage these values were 36.5% (±20.9) and 73.3% (±18.8) respectively.

Table 2. QOL-RVI of the 16 items of the questionnaire before surgery and after surgery at 3 months.

Item	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16
QOL-RVI Before surgery	1,26	2,50	2,06	2,40	1,60	1,52	2,05	1,22	1,60	1,39	1,30	1,64	1,87	1,67	1,62	1,97
QOL-RVI Before surgery (%)	12,8	74,5	52,9	69,5	29,2	25,0	51,6	11,2	29,2	19,0	14,6	32,0	42,7	32,6	30,2	47,4
QOL-RVI POST 3m	2,50	2,22	2,87	1,82	2,82	2,80	2,84	2,37	2,80	2,33	1,97	2,30	2,41	2,27	2,68	2,45
QOL-RVI POST 3m (%)	74,5	60,4	92,2	40,4	90,1	89,1	91,2	67,7	89,3	65,1	47,9	64,3	69,8	62,8	82,8	71,6

Figure 2 shows the variation in the score of the QOL-RVI obtained for each patient (every patient is a blue dot) in two different controls (preoperatively and at the 3rd month postoperatively). In this graph, when the points are located in the upper half of the table the overall quality index for that patient had improved after surgery.

Statistical correlations for the 196 patients before and after surgery at 3 months with the Spearman correlation coefficient (ρ) and P value for the statistic T Student before and after surgery showed that there was a moderate but significant relation between the estimated index before surgeries and: the UCVA log MAR before operations (-0.196 p = 0.014), the BCVA log MAR after cataract extractions (-0,35 p = 0,00018), and the age (-0,194 p = 0,007). There was no relation between the index pre or post and gender. The correlation between the QOL-RVI and the five variables described is shown in Table 3.

Table 3

Statistical correlations between variables before and after surgery at 3 months with the Spearman correlation coefficient and P value for the statistic T Student (*p < 0.05 significance level)
CORRELATION Between variables	QOL-RVI before surgery	QOL-RVI 3 months	QOL-RVI increment
UCVA PRE (LogMAR)	-0,196* (p = 0,0142)	--	--
BCVA POST (LogMAR)	--	-0,35* (p = 0,000177)	-0,309* (p = 0,001)
AGE (years)	-0,111 (p = 0,125)	-0,194* (p = 0,007)	-0,0178 (p = 0,807)
SEX	-0,08 (p = 0,270)	-0,113 (p = 0,119)	-0,00257 (p = 0,972)

QOL questionnaires have proven many times to be a useful tool for evaluating the well-being of patients after cataract surgery in in developed countries.[14, 15] However, in developing countries there are substantial differences regarding the type and severity of the pathology, the chance of the people to have successful treatment and the impact of the disease on the patient’s daily lives. In such context only a few number of papers report the real influence of this disabling disease and its treatment in Africa.[6, 14] This aspect has greater significance when considering that most of the people who are blind due to cataracts live in developing regions.[2] Studies in different populations showed that visual impairment is associated significantly with a decrease in the QOL as measured by different questionnaires.[9, 16, 17] Visual symptoms caused by cataracts are highly associated with the decrease in QOL related to vision.[18] Cataract surgery aims at improving the VA and visual function as this implies an improvement in the QOL.[19, 14] There are no references about studies on this topic in Burkina Faso, one of the poorest countries in the world.

The overall score of the questionnaire (QOL-RVI for the procedure) significantly improved 3 months after the operations. QOL scores improved postoperatively in 86.2% of patients and 95.3% of patients reported good or average at 3 months after surgery. These results are comparable to those obtained when QOL studies are conducted in developed countries.[20]

Polack et al demonstrated the validity and reliability of this questionnaire for cataract patients in Kenya, the Philippines and Bangladesh, supporting the suitability of the questionnaire as a tool for evaluation in low-income settings.[21, 22] Given the special characteristics of our patients, this questionnaire was adapted to a 16-item questionnaire.

A significant relationship between the estimated index before surgeries and both variables -UCVA before operations and also BCVA after cataract extractions- showed a direct relationship with the index and the VA. The worse the UCVA preoperatively, the worse the indexes before surgery and, in the same way, the indexes after procedures were better the better the BCVAs.

The patients operated scored qualitatively their levels of sight as “sufficient, average or bad” when the UCVAs ranged at ≥ 20/100, from 20/100 to 20/200 and < 20/200 respectively. These data should be interpreted in the context of a group of patients whose mean preoperative uncorrected VA was equal to 20/100.

To compare our index of QOL related to vision with that obtained in other series has some complexity, because there are many different models of surveys.[12] Besides validated questionnaires, some authors adapt existing ones and others create their own questionnaires.[23] The way in which the results are expressed also often differs from one study to another. Some authors give a positive value to a higher number[24] while others give it to a low number.[21] Some focus on one aspect of the questionnaire,[25] while others speak exclusively about the general score.[26]

Since we do not contemplate the VA in the contralateral eye, it could be thought that such aspect may imply a bias. However, it is important to remember that most of our patients were included for blindness due to hypermature bilateral cataract.

In our series, no significant correlation was found between the results of the questionnaire obtained during the preoperative interview (overall index of QOL) and both, age or sex. These results are consistent with studies conducted in Kenya[21] and China.[27]

The correlation between age and the overall rate at 3 months was equal to -0,194. In this case, there was a weak but statistically significant relationship, indicating that decreases in the index were more frequent in older patients. This result contrasts with those obtained in the previously mentioned studies, which found no statistical differences.[27, 21]

A significant negative correlation was found between preoperative UCVA log MAR and quality of life (the lower the VAs, the greater the QOL-RVI) and a similar result for the correlation between postoperative BCVA log MAR and QOL-RVI. These results are consistent with those published by Gothwal for questionnaire TyPE-spec and its subscales of glare and near vision, which with minor modifications was a good measure of visual function in patients with cataracts.[21] They are also consistent with the report published by Rosen et al. in a study on 233 patients where they found that the VF-14 was significantly correlated with the VA in the operated eye.[28]

The strength of the correlation between the VA and the index of QOL related to the vision depends on the characteristics of the population studied, as reported by Chan et al. In this study, a questionnaire was adapted to the Chinese population and they found that improvements in QOL correlate only moderately with improvements in the AV and patient satisfaction.[27]

This improvement in QOL related to the vision of our patients also coincides with the results published by Polack et al. They applied the WHO/PBD VF20 questionnaire a year after cataract surgery to low-income patients; and they found that QOL related to vision improved after surgery to similar levels to those of the population with normal vision.[21]

QOL scores improved postoperatively in 90.2% of patients, did not change in 3.1% and were worse in 6.7%. Chan et al found slightly lower values in Hong Kong four months after surgery,[27] as the questionnaire of QOL improved in 83.6% of patients postoperatively, remained unchanged in 3.6% and was worse in 12.7%. In this same study, generally questionnaire scores improved in all domains after surgery by 0.68 times, whereas the improvement in our study was 1.42 times. Regarding the patients who reported a decrease in QOL after the surgery, it is important to point out that the evolutive degree of the cataract did not allow examination of the posterior segment of the eye in many cases. So, when a patient suffering some unnoticed comorbidity that could limit postoperative visual improvement was operated, it is reasonable to think that the procedure decreased his QOL.

Finally, it is necessary to indicate that, considering that the majority of patients operated had very poor vision in both eyes, the population analyzed presented an ideal profile to correlate an improvement in visual function with the perceived QOL. On the other hand, the low literacy rate of the patients (22%) was a challenge when it comes to responding to the questionnaire.

It can be concluded from our study that cataract surgery increases the QOL of patients living in a developing country such as Burkina Faso and that the improvement correlates with the recovery of the visual acuity.

Acknowledgements: Rosalie Sanon and Blaise Ouédraogo

Financial disclosure: The authors have no proprietary or commercial interest in the medical devices that are involved in this manuscript.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Competing Interests

The authors have no relevant financial or non-financial interests to disclose.

Author Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Isabel Signes-Soler, Jaime Javaloy, Robert Montés-Micó, Gonzalo Muñoz, Raúl Montalbán Llamusí, Ana Maria Hernandez Baeza, César Albarrán-Diego. The first draft of the manuscript was written by Isabel Signes-Soler and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Research Ethics Approval

Consent to participate

Informed consent was obtained from all individual participants included in the study.

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No competing interests reported.

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Vision-related Quality of Life After Cataract Surgery in West Africa

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Abstract

Figures

Introduction

Material And Methods

Study design

Studied population

Questionnaire: variables for the study and methodology of the interviews

Variables for the study

Results

Visual acuity outcomes

Discussion

Statements And Declarations

References

Competing Interests

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