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. 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. 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.
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. Besides validated questionnaires, some authors adapt existing ones and others create their own questionnaires. 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 while others give it to a low number. Some focus on one aspect of the questionnaire, while others speak exclusively about the general score.
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 and China.
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. 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.
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.
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.
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, 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.