Vision-related quality of life after surgery for vitreoretinal disorders: an observational study

doi:10.21203/rs.3.rs-1735173/v1

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Vision-related quality of life after surgery for vitreoretinal disorders: an observational study

https://doi.org/10.21203/rs.3.rs-1735173/v1

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Background: Visual-related quality of life is not always included as a variable of surgical success. However, some questionnaires such as the Visual Function Quality-25 in the Spanish version have proven their reliability and validity, but the quality of life in patients undergoing surgery has not been explored in the Mexican population; so, this study aims to identify it in patients with the most prevalent vitreoretinal diseases.

Methods: The Visual Function Quality-25 questionnaire was applied to 76 patients with advanced diabetic retinopathy, rhegmatogenous retinal detachment, and other causes of vitrectomy, pre-and postoperative. It was divided into 10-domains and interpreted according to the National Eye Institute scores, where the highest value was the best visual function. Student's t-test for related samples and Wilcoxon's t-test were used to compare each domain between measurements, and Pearson´s R test to correlate age and quality of life total score; a p-value <0.05 was considered significant.

Results: Diabetic retinopathy patients showed an improvement after surgery in all domains, one and three months after surgery; the higher scores were in those who used air o gas as tamponade. In patients with rhegmatogenous retinal detachment, there was an improvement in almost all the items from the first month, with a higher difference observed up to three months, while a decrease in ocular pain was observed in other causes of vitrectomy. Differences found in all the quality-of-life scores at one versus three months were not statistical, but clinically significant.

Conclusions: The study shows that visual-related quality of life domains improve after vitrectomy, predominately in diabetic retinopathy subjects; inclusion of this analysis might be considered relevant within the parameters of surgical success of the most prevalent vitreoretinal diseases.

quality of life

retinal surgery

visual function

vitrectomy

The World Health Organization (WHO) defines the quality of life as the perception that an individual has in the context of their culture, the values in which they live, their expectations, norms, and concerns [1]. Consists of both objective components and material circumstances of life, for example, illness, pain, disability, and other factors added to subjective components that are mainly the degree of satisfaction and the perception of living conditions [2].

Currently, it is not enough to assess the value of visual acuity and the visual field as surgical success, so the quality of life perceived after eye surgery must be included. There are some instruments to assess the quality of life and visual function, including The Visual Disability Assessment (VF-14) [3], Activities of Daily Vision Scale (AVDS) [4], Quality of Life Questionnaire (QOLQ) [5], Visual Function Quality-39 (VFQ-39) [6] and Visual Function Quality-25 (VFQ-25) [7]; the latter has demonstrated validity and reliability for different populations in distinct languages in the 25-item adaptation derived from the original 51-item [8].

The questionnaire measures the influence of visual disability and visual symptoms in physical and mental health domains, in addition to those related to visual functioning, problems involving vision, or the patient’s perception of their vision condition [9]. It has been evaluated in Spanish [10], for Latino patients living in the United States [9], Cubans [8], and Colombians [11], where internal reliability coefficients are lower than those necessary in the items of general health and driving (so they are eliminated from the questionnaire in its Spanish version) [8,10].

It has been translated and adapted to the cultural environment and validated in Serbian, Turkish, Chinese, Japanese, Greek, French, Italian, Polish, Portuguese, and Spanish [9,10]. Among the retinal pathologies in which it has been evaluated, Okamoto and his group [12] report a higher preoperative and postoperative score for macular hole and epiretinal membrane and retinal detachment. The VQF-25 has become a tool that has been used to assess the quality of life in subjects with cataracts [13], glaucoma [14], age-related macular degeneration [15], and diabetic retinopathy [16], among others.

However, to date, the VFQ-25 questionnaire in its Spanish version has not been applied to the most prevalent retinal pathologies in Mexico. Our objective was to identify the quality-of-life score related to vision in patients with vitreoretinal diseases who undergo retinal surgery in a reference ophthalmological hospital and determine which are the domains of quality of life with higher impact after surgery.

It is an observational, prospective, comparative, and longitudinal study. Seventy-six patients between 18-and 80 years with diabetic retinopathy, rhegmatogenous retinal detachment, and other vitreoretinal pathologies (macular hole, epiretinal membrane, and causes of vitreous haemorrhage), were included. Patients were followed-up after a vitrectomy at one and three months in person or by telephone between May and August 2019; they agreed to participate, understood, and signed the informed consent. This study followed the principles established in the Declaration of Helsinki and was approved by the Institutional Review Board of the hospital where it took place. The data was handled and analyzed with strict confidentiality and according to good clinical practices.

The demographic variables considered were age and sex, and the best-corrected visual acuity (BCVA) was recorded before the intervention, which was converted to the minimum angle of resolution (logMAR) for statistical calculations. Within the approximations, finger count was considered as 20/2000, hand movement=20/4000, and light perception=20/8000.

The researchers applied the Visual Function Quality-25 test; the questionnaire was divided into 10-domains: 1) general vision, 2) eye pain, 3) close activities, 4) distance activities, 5) social functioning, 6) mental health, 7) role limitations, 8) dependence, 9) colour vision, and 10) peripheral vision. The Spanish version excludes the general health and driving items from the algorithm, for which there are 23 items [8]; its application time was less than 15 minutes. The researchers explained the questionnaire to the patients at the beginning of the application and provided additional support when necessary.

For the calculation and interpretation of the results, the National Eye Institute (NEI) scoring algorithm was used [17], which considers the subscales with a score from 0 to 100, where 100 is the highest function. The total score was the mean of all items; in case an answer to a question was not related to vision or did not apply to the context, it was excluded from the overall score.

Statistical analysis

The Kolmogorov-Smirnov statistical test evaluated the data distribution; only items 3, 7, and 8 in the diabetic retinopathy group did not have a normal distribution. The means comparison of each domain was by Student's t-test for related samples and Wilcoxon's t-test, as appropriate, and the variable quality of life total score between the different types of tamponades was calculated using Kruskal-Wallis. Also, the correlation coefficient of the total score concerning age was obtained by the Pearson's R test, which considered an r<0.4 as a weak correlation, r≥0.4-0.7 moderate, and r>0.7 a strong correlation; a p-value <0.05 was considered significant. Data were stored and analyzed in GraphPad Prism version 8.0 for Mac.

Of the sample (n = 76), mean age was 50.4 ± standard deviation (S.D.) 10.19 years, 44 men (57.89%) and 32 women (42.11%); 54% of the patients undergoing surgery for advanced diabetic retinopathy (n = 41), 30% for rhegmatogenous retinal detachment (n = 23), and 12% for other causes of vitrectomy (n = 12).

Forty-one patients diagnosed with advanced diabetic retinopathy aged 53.27 years ± 9.06; 61% (n = 25) were men. The evaluation included 21 right and 21 left eyes. For this group, the preoperative quality-of-life total score was 43.01 ± 18.19 points, after one month 57.62 ± 20.95, and at three months 59.17 ± 19.11 (Table 1); the rest of the items also showed improvement in quality of life at one month, although the subjects evaluated reported higher ocular pain after surgery than before it (p < 0.001). This statistical difference persisted when the pre-surgical evaluation was compared with the three months follow-up after the intervention, except in the general vision and social performance items, although in both cases quality of life improved.

Table 1

Comparison of quality-of-life related variables of pre-and post-surgical evaluations, in advanced diabetic retinopathy.
Domain	PreOp vs. one-month*		PreOp vs. three-months*		One month vs. three months*
Domain	Mean (SD)	p	P Mean (SD)	p	Mean (SD)	p
Total Score	43.00 (18.18) − 57.51 (20.94)	< 0.001	43.00 (18.18) − 59.17 (19.11)	0.001	57.51 (20.94) − 59.17 (19.11)	0.60
General vision	41.95 (14.70) − 65.52 (23.23)	0.03	41.95 (14.70) − 63.95 (18.15)	0.41	65.52 (23.23) − 63.95 (18.15)	0.16
Ocular pain	85.67 (15.94) − 73.27 (23.08)	< 0.001	85.67 (15.94) − 81.57 (17.86)	< 0.001	73.27 (23.08) − 81.57 (17.86)	0.19
Near vision**	16.67 (8.33–45.83) − 50 (25-79.17)	< 0.001	16.67 (8.33–45.83) − 50 (33.33-75)	0.001	50 (25-79.17) − 50 (33.33-75)	0.20
Distance vision	39.32 (27.99) − 52.68 (29.24)	< 0.001	39.32 (27.99) − 51.09 (29.32)	0.001	52.68 (29.24) − 51.09 (29.32)	0.91
Social functionality	43.90 (32.37) − 64.65 (31.53)	0.04	43.90 (32.37) − 63.81 (29.43)	0.12	64.65 (31.53) − 63.81 (29.43)	0.94
Mental health	32.93 (26.33) − 44.18 (26.51)	0.008	32.93 (26.33) − 43.42 (29.71)	0.01	44.18 (26.51) − 43.42 (29.71)	0.29
Role limitations**	25 (0–50) − 50 (25–75)	0.02	25 (0–50) − 50 (25–75)	0.01	50 (25–75) − 50 (25–75)	0.30
Dependence**	25 (0–50) − 50 (16.67–83.33)	0.002	25 (0–50) − 50 (25–75)	< 0.001	50 (16.67–83.33) − 50 (25–75)	0.74
Color vision	75 (34.46) − 81.89 (26.64)	0.001	75 (34.46) − 77.63 (23.41)	< 0.001	81.89 (26.64) − 77.63 (23.41)	0.73
Peripheral vision	46.34 (22.05) − 65.52 (29.43)	< 0.001	46.34 (22.05) − 69.74 (24.41)	< 0.001	65.52 (29.43) − 69.74 (24.41)	0.74
^{Paired student´s t−test, *Wilcoxon´s t test, PreOp = preoperative}

Neither of the cases had a significant difference in the scores obtained when the one-month and three months after surgery; there was also no difference between sex and the quality-of-life total score before surgery (p = 0.27), at one month (p = 0.93), and three months (p = 0.18). Regarding the type of tamponade, there was a higher quality of life pre-surgical score when the tamponade was air/gas versus silicone (p = 0.04). The correlation between age and the pre-surgical total score had a weak positive linear correlation (r = 0.15, p = 0.34), but this changed when evaluating the total score one month (r = 0.43) and three months (r = 0.47) after surgery, where existed moderate positive correlations with statistical significance (p < 0.05, Figs. 1 and 2).

In patients undergoing surgery for rhegmatogenous retinal detachment, the mean age was 51.43 ± 12.31 years; 61% (n = 14) were men. The evaluation included 15 right eyes and eight left eyes. The higher quality of life scores were mental health and role difficulty items one month after surgery compared to the pre-surgical evaluation (p < 0.05, Table 2); however, the difference did not appear between the two post-surgical total scores. Five items showed significant improvement three months after surgery, and only the ocular pain variable had a higher score before surgery. There was also no change at one month and three months after surgery in the pre-surgical total score concerning patient sex or the type of tamponade (p > 0.05). In the correlation analysis, existed negative linear relations between age and the total score at one month (r= -0.44) and three months (r= -0.27), although there was no statistical difference (p > 0.05).

Table 2

Comparison of quality-of-life related variables of pre-and post-surgical evaluations, in rhegmatogenous retinal detachment.
Domain	PreOp vs. one-month*		PreOp vs. three-months*		One month vs. three months*
Domain	Mean (SD)	p	Mean (SD)	p	Mean (SD)	p
Total Score	58.04 (18.30) − 61.65 (17.77)	0.02	58.04 (18.30) − 67.88 (11.01)	0.06	61.65 (17.77) − 67.88 (11.01)	0.99
General vision	46.09 (12.70) − 66.67 (10)	0.09	46.09 (12.70) − 65.71 (9.76)	0.04	66.67 (10) − 65.71 (9.76)	0.99
Ocular pain	85.76 (20.54) − 79.16 (20.73)	0.59	85.76 (20.54) − 82.14 (14.17)	0.04	79.16 (20.73) − 82.14 (14.17)	0.21
Near vision	48.19 (28.42) − 49.07 (33.18)	0.11	48.19 (28.42) − 65.48 (12.20)	0.19	49.07 (33.18) − 65.48 (12.20)	0.74
Distance vision	59.78 (34.23) − 62.96 (34.45)	0.64	59.78 (34.23) -	0.15	62.96 (34.45) -	0.39
Social functionality	67.93 (33.03) − 63.89 (36.14)	0.35	67.93 (33.03) − 65.48 (27.92)	0.18	63.89 (36.14) − 65.48 (27.92)	0.39
Mental health	44.84 (25.95) − 51.39 (220.5)	0.02	44.84 (25.95) − 76.78 (34.93)	0.002	51.39 (220.5) − 76.78 (34.93)	0.69
Role limitations	25 (0–50) − 62.50 (12.50–87.50)	0.02	25 (0–50) − 75 (37.50–87.50)	0.02	62.50 (12.50–87.50) − 75 (37.50–87.50)	0.71
Dependence	57.61 (35.35) − 65.74 (29.30)	0.99	57.61 (35.35) − 70.23 (23)	0.41	65.74 (29.30) − 70.23 (23)	0.36
Color vision	90.21 (19.57) − 83.33 (21.65)	0.24	90.21 (19.57) − 89.28 (13.36)	0.03	83.33 (21.65) − 89.28 (13.36)	0.69
Peripheral vision	58.69 (22.12) − 75 (33.07)	0.14	58.69 (22.12) − 78.57 (22.49)	0.02	75 (33.07) − 78.57 (22.49)	0.52
^{*Paired student´s t−test}
^{PreOp = preoperative}

Regarding other causes of vitrectomy analyzed, the mean age was 53.17 ± 10.12 years; 58.3% (n = 7) were women. The evaluation included 11 right eyes and one left. The quality-of-life total score was 56.14 ± 10.11 before surgery, 66.49 ± 18.63 at one month, and 63.59 ± 24.59 at three months. Only the ocular pain variable showed a higher quality of life after surgery with statistical significance when compared with pre-surgical evaluation (Table 3). Quality-of-life items compared with the type of tamponade or patient sex had no difference but a weak positive correlation between age and the pre-surgical total score, not significant (r = 0.17, p = 0.59).

Table 3

Comparison of quality-of-life related variables of pre-and post-surgical evaluations, in other causes of vitrectomy.
Domain	PreOp vs. one-month*		PreOp vs. three-months*		One month vs. three months*
Domain	Mean (SD)	p	Mean (SD)	p	Mean (SD)	p
Total Score	56.14 (14.44) − 66.49 (18.62)	0.27	56.14 (14.44) − 63.59 (24.32)	0.44	66.49 (18.62) − 63.59 (24.32)	0.73
General vision	56.67 (14.35) − 54 (12.65)	0.17	56.67 (14.35) − 64.44 (19.43)	0.40	54 (12.65) − 64.44 (19.43)	0.91
Ocular pain	81.25 (17.27) − 71.25 (24.33)	0.002	81.25 (17.27) − 66.67 (31.87)	0.008	71.25 (24.33) − 66.67 (31.87)	0.67
Near vision	33.33 (21.90) − 58.33 (27.78)	0.87	33.33 (21.90) − 62.03 (25.72)	0.61	58.33 (27.78) − 62.03 (25.72)	0.50
Distance vision	61.11 (19.08) − 65.41 (28.87)	0.18	61.11 (19.08) − 59.72 (28.87)	0.99	65.41 (28.87) − 59.72 (28.87)	0.17
Social functionality	63.54 (22.27) − 77.50 (22.67)	0.14	63.54 (22.27) − 66.67 (32.47)	0.87	77.50 (22.67) − 66.67 (32.47)	0.14
Mental health	48.44 (23.10) − 61.87 (18.97)	0.53	48.44 (23.10) − 51.39 (23.13)	0.33	61.87 (18.97) − 51.39 (23.13)	0.18
Role limitations	41.66 (35.89) − 50 (28.87)	0.27	41.66 (35.89) − 58.33 (27.95)	0.61	50 (28.87) − 58.33 (27.95)	0.90
Dependence	54.86 (28.30) − 69.17 (30.44)	0.68	54.86 (28.30) − 68.52 (34.80)	0.22	69.17 (30.44) − 68.52 (34.80)	0.17
Color vision	93.75 (15.54) − 90 (21.08)	0.05	93.75 (15.54) − 83.33 (27.95)	0.59	90 (21.08) − 83.33 (27.95)	0.41
Peripheral vision	54.17 (20.87) − 72.22 (23.20)	0.14	54.17 (20.87) − 63.89 (35.60)	0.58	72.22 (23.20) − 63.89 (35.60)	0.77
^{*Paired student´s t−test}
^{PreOp = preoperative}

Our study found an increase in quality of life one month after vitrectomy in each group, and increased up to 16 points when compared pre-surgical vision quality versus three months after vitrectomy evaluation, in patients with advanced diabetic retinopathy, 9 points in patients with rhegmatogenous retinal detachment, and six points in patients undergoing surgery for other reasons. The type of air/gas tamponade showed a better quality of life score compared to those in which silicone was used, this may be because its use is generally limited to the most complex retinal disease cases who perceive a lower quality of life related to vision; additionally, a correlation was identified between older age and an improvement in the quality-of-life score after surgery, particularly in patients with diabetic retinopathy.

These findings contrast with the reported by Okamoto and his group [18], who applied the test to 51 patients diagnosed with diabetic retinopathy before undergoing surgery and three months later; the score reported in vitreous haemorrhage was 51.2 to 62.3, tractional retinal detachment 61.1 to 70.3 and excessive macular traction 55.2 to 59.4. The subscales that reported significant improvement after surgery were general vision, near and distance activities, social function, mental health, role difficulty, driving, and peripheral vision. However, no correlation was shown with age, duration of diabetes, HbA1C levels, or fasting glucose. In our study, it was observed that the preoperative score was below the reported by Okamoto (43.00); however, the results after surgery are similar (57.51 and 59.17), indicating a significant improvement in the quality of life of patients undergoing vitrectomy in our country.

The quality-of-life total score in cases of rhegmatogenous retinal detachment has been reported at 80 points in women and 74.7 in men with follow-up at 6 months; according to Smeretschnig, the items with the greatest difference concerning normal controls were general vision, mental health, social functionality, driving, and colour vision [20]. On the other hand, a group reported this difference at 3 months of operated patients versus controls, in near activities, peripheral vision, dependency, and mental health [19], whose findings coincide with those of Du and his team [21], although the latter applied the questionnaire one day before surgery. We compared the same patients over time and found a significant difference in the composite score, about mental health and role difficulty during the first month, while at three months these same variables are preserved, general vision showed an improvement, and eye pain, colour vision, and peripheral vision scores decreased; it may be possible that the changes reported in each item are higher the more time passes after surgery, but this requires an additional long-term study.

In epiretinal membranes, vitrectomy has significantly improved the components of quality of life, being the most important post-surgical improvement among the pathologies studied [12]. It mainly impacts 10 subscales except for peripheral vision and general health (mean score 77.9). The results seem to be directly related to the presence and severity of preoperative metamorphopsia, but not visual acuity, contrast sensitivity, or central macular thickness [22]. On the contrary, Ghazi reports that there is an improvement of the metamorphopsia-perception after surgery, and considers that the initial visual acuity correlates with the initial VFQ-25 score; however, in his study, VA does not improve considerably after surgery, and only remote activities, general vision, and the overall score had an improvement [23]. Matsuoka [24] has reported that the greatest improvement-related items at 3 months after surgery are visual capacity, general vision, close activities, role difficulties, and the composite score, while at 12 months it is the improvement of the metamorphopsia-perception, general vision, close activities, distance activities, mental health, role difficulty, and the composite score. In this study, we found no difference in the pre-and post-surgical quality of life for this pathology, which was included in other causes of vitrectomy; the only item with a statistical difference was the eye pain that improved after surgery in the first month. However, further analysis is required to evaluate the quality of life and its correlation with the visual function test.

It is important to consider the quality of life as one of the variables within surgical success that are observed to increase, after surgery for retinal pathologies, which is more noticeable in older patients (43% in the evolution at one month), and in 47% of the cases three months after the intervention, which represents a 30% of change concerning the quality of life prior the vitrectomy, according to our findings. The relevance relies on the high prevalence of these diseases in our population and their poor control; to our knowledge, it is the first report of quality of life related to vision in patients undergoing vitrectomy in Mexico.

In conclusion, vitrectomy performed in patients with advanced diabetic retinopathy improves the quality-of-life score associated with vision and in each of the items from the first month after surgery, while for rhegmatogenous retinal detachment the relevant improvement is observed up to three months after surgery. Another prospective study with a long-term follow-up that considers vision and sensory tests is suggested, in addition to increasing the sample of patients.

Ethics approval and consent to participate

Approval was obtained from the ethics committee of Fundación Hospital Nuestra Señora de la Luz IAP. The procedures used in this study adhere to the tenets of the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study.

Consent to publication

Not applicable

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing Interest

The authors (Ilse Sarahí Márquez Vergara, Geovanni Jassiel Ríos-Nequis, Ingrid Yasmín Pita-Ortíz, Héctor Javier Pérez-Cano and Selma Alin Somilleda-Ventura) declare that they have no conflict of interest.

Funding

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

Author Contributions

All authors contributed to the conception and design of the study. Material preparation, data collection and analysis were performed by Ilse Sarahí Márquez Vergara, Geovanni Jassiel Ríos-Nequis and Ingrid Yasmín Pita-Ortíz. The first draft of the manuscript was written by Ilse Sarahí Márquez Vergara, Héctor Javier Pérez-Cano and Selma Alin Somilleda-Ventura, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

Not applicable

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No competing interests reported.

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Vision-related quality of life after surgery for vitreoretinal disorders: an observational study

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