June 2009
Volume 50, Issue 6
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Eye Movements, Strabismus, Amblyopia and Neuro-ophthalmology  |   June 2009
Vision- and Health-Related Quality of Life in Patients with Visual Field Loss after Postchiasmatic Lesions
Author Affiliations
  • Carolin Gall
    From the Otto-von-Guericke University of Magdeburg, Medical Faculty, Institute of Medical Psychology, Magdeburg, Germany; and the
  • Johanna Lucklum
    From the Otto-von-Guericke University of Magdeburg, Medical Faculty, Institute of Medical Psychology, Magdeburg, Germany; and the
  • Bernhard A. Sabel
    From the Otto-von-Guericke University of Magdeburg, Medical Faculty, Institute of Medical Psychology, Magdeburg, Germany; and the
  • Gabriele H. Franke
    University of Applied Sciences Magdeburg-Stendal, AHW, Department of Rehabilitation Psychology, Stendal, Germany.
Investigative Ophthalmology & Visual Science June 2009, Vol.50, 2765-2776. doi:10.1167/iovs.08-2519
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      Carolin Gall, Johanna Lucklum, Bernhard A. Sabel, Gabriele H. Franke; Vision- and Health-Related Quality of Life in Patients with Visual Field Loss after Postchiasmatic Lesions. Invest. Ophthalmol. Vis. Sci. 2009;50(6):2765-2776. doi: 10.1167/iovs.08-2519.

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      © ARVO (1962-2015); The Authors (2016-present)

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Abstract

purpose. The purpose of the study was to assess vision-related quality of life (QoL) in patients with visual field loss (VFL) after lesions of the postchiasmatic visual pathway and to investigate the influence of VFL and reduced visual acuity (VA) on vision-related QoL.

methods. In 312 patients with postchiasmatic damage, VFL was measured by automated computer campimetry, and vision-related QoL was assessed by the National Eye Institute Visual Functioning Questionnaire (NEI-VFQ). Health-related QoL was obtained by the SF-36 Health Survey in 272 patients. In addition, 90° visual fields and VA data were obtained. NEI-VFQ and SF-36 scores were compared with those of healthy subjects and poststroke, brain-injured patients in general. Multiple analyses of covariance and multiple linear regression models for QoL results were performed with VA and VFL as independent variables.

results. Patients with postchiasmatic lesions who had VFL had markedly lower NEI-VFQ scores than did healthy subjects and also lower SF-36 scores than did poststroke, brain-injured patients, particularly in the domain of role functioning. VFL and VA correlated significantly with vision-related but not with health-related QoL estimates when age was considered as confounding variable. Most scales of NEI-VFQ (9/12) were sensitive to differences in VFL.

conclusions. VFL and VA had a coordinate influence on vision-related QoL in brain-injured patients with postchiasmatic lesions. Diminished health-related QoL was not associated with VFL and VA. Both VFL and VA should be considered when trying to explain variance of NEI-VFQ results in patients with postchiasmatic lesions of the visual pathway.

Because of the demographic development in Western societies and declining stroke mortality rates, there is an increasing number of patients with visual field impairments caused by different etiologies. 1 Visual field loss (VFL) may occur after lesions to the eye (e.g., glaucoma and age-related macula degeneration), to the optic nerve (e.g., optic neuropathy after trauma) or after lesions of the postchiasmatic pathway (e.g., after stroke, tumor, or trauma). VFL leads to impairments in activities of daily life such as reading, driving, or overall orientation and may therefore have severe impact on the patients’ well-being and QoL. 2  
Although there are many studies assessing self-rated disabilities after stroke using questionnaires of general health-related QoL, 3 4 5 only a few studies focused on the assessment of vision-related QoL in patients with VFL after cerebral damage. 6 7 Vision-related QoL was often described in patients with different ophthalmic diseases such as glaucoma, 8 9 10 11 12 cataract, 13 age-related macular degeneration, 14 benign essential blepharospasm, 15 16 juvenile macular dystrophy and retinitis pigmentosa, 17 and retinal vein occlusion. 18 Diminished QoL was observed in each of the mentioned diseases, even when age was considered a possible confounding variable. In studies which focus on the impact of objective VFL on subjective vision- and health-related QoL, the National Eye Institute Visual Functioning Questionnaire (NEI-VFQ) was often used as a valid and reliable instrument. 8 10 19 20 21 22  
Most studies focus on QoL in patients with VFL due to glaucoma. For instance, McKean-Cowdin et al. 10 studied VFL in 213 patients with open-angle glaucoma and compared the results with a reference population of 2821 subjects without glaucoma or impairments to the visual field. They found that patients with lower thresholds in Humphrey automated perimetry (4- to 5-dB differences; Carl Zeiss Meditec, Oberkochen, Germany) also reported lower scores in the NEI-VFQ composite score and in most subscales of the NEI-VFQ. In addition, patients with central VFL had lower scores compared to patients with peripheral VFL and patients who had glaucoma without manifest VFL reported better scores than patients with VFL. Gutierrez et al. 8 reported correlations between the size of glaucomatous VFL and NEI-VFQ subscales of r = −0.2 to −0.6. Thus, there is a considerable association between glaucomatous VFL and vision-targeted QoL. 
However, much less is known about vision-related QoL in patients with homonymous VFL. This topic was first studied in a small sample of 33 postchiasmatic patients by Papageorgiou et al. 6 Compared with a healthy reference group (mean composite score of 90.6), postchiasmatic lesioned patients had a significantly worse composite score (77.1) and also significantly lower scores in 7 of 12 NEI-VFQ subscales: general vision, near vision, vision specific mental health, driving, color, peripheral vision, and general health. In a previous study, 7 we found that patients with visual field defects after cerebral damage (n = 24) had not only significantly lower vision-related QoL values than healthy subjects but also lower than those in patients with VFL due to diseases other than cerebral damage (i.e., glaucoma and optic neuritis). 22 23 In this study, the correlation between the remaining visual field size in static 90° perimetry and the NEI-VFQ composite score was r = 0.67. 7 When the NEI-VFQ composite score was correlated to the area of sparing within the affected hemifield (instead of the whole intact visual field size) the correlation was r = 0.38. 6  
The purpose of the present study was to examine whether visual field parameters of the central and peripheral visual field are associated with self-reported vision- and health- related QoL in a larger sample of patients with VFL due to postchiasmatic lesions. We further studied how the topography of the VFL and the area of sparing within the central visual field relate to the patients’ vision- and health-related QoL estimates. 
Unlike the study by Papageorgiou et al. 6 patients with postchiasmatic lesions and those without associated hemispatial neglect were included in our study. In fact, one reason that there are so few studies of QoL assessment in patients with VFL after postchiasmatic lesions may be that some of these patients have superimposed hemianopia and hemispatial neglect. 24 Furthermore, it is well known that cerebrally damaged patients frequently have anosognosia, which may introduce a sample selection bias. 25 To study the impact of neglect symptoms on the assessment of vision-related QoL in patients with postchiasmatic lesions we did not exclude these patients but compared their QoL estimates to those of patients with postchiasmatic lesions without visual hemineglect. 
Material and Methods
Subjects
The main inclusion criterion for study entry was the presence of VFL after postchiasmatic lesions to the visual pathway, as indicated by campimetry and/or standard perimetry. Patients with epilepsy or photosensitivity were generally excluded from the study. One hundred patients with postchiasmatic VFL were recruited from the database of the Institute of Medical Psychology at the University of Magdeburg (Germany) and a further 212 patients at the NovaVision Center of Excellence for Visual Therapy (Magdeburg). All patients were treated according to the standards of the Declaration of Helsinki (1964). 
The total sample consisted of 312 patients with homonymous visual field defects after postchiasmatic damage. There were no significant differences between patients who were going to participate in neurovisual rehabilitation and untreated patients with respect to QoL and VFL data (all F < 1.0). 
The mean age of the sample was 53.6 years (range, 9–84); 35.5% of the investigated patients were female. The mean age of the lesion was 32.9 months (SD 4.62). In 51.42% of cases, the lesion was older than 12 months and in 72.34%, older than 6 months. 
About half of the patients had left-side VFL with 41.9% of cases with hemianopic VFL, 7.6% with quadrantanopia, and 1.0% with scotoma; 26.6% of the patients had right-side VFL with 20.3% hemianopia, 6.0% quadrantanopia, and 0.3% scotoma; and 22.9% of the patients had VFL affecting both sides, including 14.2% of patients with diffuse VFL, 5.0% with VFL in three quadrants, 3.0% tunnel vision, and 0.7% with scotoma. 
In the majority (59.3%) of the cases, the etiology of the visual field defect was ischemic infarction. The remaining 126 patients had hemorrhagic infarctions (16.7%), nonprogressive or extirpated brain tumors (12.2%), traumatic brain injury (9.6%), encephalitis (1.3%), ectomy for epilepsy (0.6%), or anoxic brain (0.3%). 
In cases in which neuropsychological reports indicated the presence of severe attentional disorders or hemispatial neglect, these patients were examined with the German version (NET) of the Behavioral Inattention Test (BIT). 26 This permitted a direct comparison of patients with postchiasmatic lesions, with (n = 35) or without (n = 277) hemispatial neglect. Clinically, hemianopia and any kind of predominantly left-side VFL may coincide with hemispatial neglect. Neglect may also show up without any restriction of the visual field; however, these patients were not included in the present study, because they did not have postchiasmatic VFL. 
Of 35 patients showing hemispatial neglect, 34 patients were included in the group comparison; 1 outlier with right-side VFL from right-side hemispatial neglect was excluded. Based on the group of those with neglect, two further groups (left-side and right-side hemianopics without neglect) were formed by matching for age and visual acuity (VA) to the group of patients with neglect. 
QoL Measures
The NEI-VFQ was originally designed to measure the dimensions of self-reported, vision-related QoL that are important for patients with chronic eye disease. 19 It has been shown that the NEI-VFQ is also useful in patients with VFL after cerebral damage. 6 7 The validated German 39-item version of the NEI-VFQ was used in self-administered format. 27 It measures the influence of visual disability and visual symptoms on generic health domains. The questionnaire consists of 39 rating items with 12 subscales: The dimensions 2 to 5 assess the patients’ visual disabilities and 6 to 12 assess difficulties that are the result of visual impairment. The dimensions were as follows: 1, general health (two items); 2, general vision (two items); 3, ocular pain (two items); 4, difficulties with near-vision activities (six items); 5, difficulties with distance vision activities (six items); 6, limitations in social functioning due to vision (three items); 7, mental health symptoms due to vision problems (five items); 8, role difficulties due to vision problems (four items); 9, dependency on others due to vision problems (four items); 10, driving problems (three items); 11, color vision problems (one item); and 12, peripheral vision problems (one item). 
Two composite scores were generated: one by averaging all 12 dimensions including general health which was common in earlier NEI-VFQ studies, the second by averaging only 11 scales without general health which was suggested by the developer of the NEI-VFQ in the revised manual (www.nei.nih.gov/resources/visionfunction/manual_cm2000.pdf). Subscales and composite scores ranged from 0 (worst possible functioning) to 100 (best possible functioning). 
The Health Survey Short Form SF-36 is a standard instrument for the collection of data concerning general health-related QoL. Based on self-report, this questionnaire was used to quantify health-related QoL in patients, independent of their actual state of health or their age. The questionnaire consists of a 36-item list that can be subdivided into eight dimensions of subjective health: physical functioning (10 items), role limitations due to physical problems (4 items), bodily pain (2 items), general health perceptions (5 items), vitality (4 items), social functioning (2 items), role limitations due to emotional problems (3 items), and emotional well-being (5 items). In addition, there is one item (self-reported health transition) that is not part of these eight dimensions. All items can be combined to form two summary scales resulting in the physical component score (PCS) and the mental component score (MCS). The categories for answering the questions vary from yes-or-no-decisions to 6-point rating scales. Component scores were generated by adding the item responses and including given loadings for the different dimensions. Subscale and component scores ranged from 0 (worst possible functioning) to 100 (best possible functioning). In the present study, the German translation of the SF-36 was self-administered, patients were asked to rate the items based on the experiences during the past 4 weeks. 28  
For an optimal measurement of QoL in visually impaired persons, it is reasonable to use both questionnaires: the SF-36 for general health status and the NEI-VFQ for vision-targeted questions. 21 NEI-VFQ and SF-36 were sent to all patients by regular mail because answering self-administered questionnaires at home is known to result in more realistic estimates than questionnaires completed in interviews or while an investigator is present. 29 However, in contrast to face-to-face interviews postal surveys cannot fully exclude family assistance during the completion of the questionnaires. We therefore instructed family members to avoid assisting. Fourteen subjects were not able to answer the questionnaires without assistance. In these cases family members were instructed to read the questions and the answer options aloud, avoiding any discussion and/or explanations of the questions, and to mark the answer option chosen by the patient. 
Visual Field Diagnostics
VFL was assessed with a campimetric visual field test. 30 The patients were seated in a darkened room in front of a 17-in. monitor. The head position was stabilized by a combined head–chin rest. The distance between the eyes and the screen was approximately 40 cm. White-light stimuli were presented in a grid of 25 × 19 stimulus locations. The order of stimulus positions was randomized. A fixation point positioned at the center of the screen served as the frame of reference to set up the screen at eye level. The subject was instructed to keep looking at the fixation point and to press the space bar on the computer keyboard whenever either a target stimulus was detected or when an isoluminant change in the color of the fixation point occurred. Correctly detected stimuli, misses, false positives, fixation losses as well as reaction times were registered. Three measurements were performed, each with duration of approximately 23 minutes. Visual field areas were categorized as intact (three correctly detected stimuli per location, white spots), partially damaged (one or two stimuli detected, gray spots) and absolutely impaired areas (no stimulus detected, black spots; Fig. 1 ). The extent of VFL in the campimetric visual field test corresponds to the number of black spots (percentage). 
Analogous to the area of sparing within the affected hemifield defined by Papageorgiou et al., 6 we defined a central 5° area on the side of the VFL (14 stimuli positions in campimetry) which was then categorized as intact, partially damaged, and absolutely impaired. Campimetry was performed in the whole patient sample (n = 312) and reliability parameters were as follows: mean percentage of fixation accuracy, 91.78% (SD 12.61%); mean percentage of false positive results 2.57% (SD 4.59%). 
In a subset of 148 patients, the 90° visual field was additionally measured with static automated perimetry. In each patient one of three perimeters with different grids was used: Humphrey Field Analyzer (81 positions; Carl Zeiss Meditec), Twinfield (96 positions; Oculus, Lynnwood, WA), and Rodenstock Perimat 206 (133 or 206 positions; Linos Photonics, Göttingen, Germany). Because the number of tested position varied, VFL was calculated as a percentage value of absolute defects in the 90° visual field. Perimetry reliability parameters of the investigated sample (n = 148) were as follows: The mean percentages of missed central fixation were 87.64% (SD 18.81%) for the right eye and 78.36% (SD 24.32%) for the left eye. The mean percentages of correct false-positive catch trials were 96.43% (SD 12.39%) for the right eye and 98.30% (SD 6.86%) for the left eye. 
VA and Reading Speed
In 153 patients with postchiasmatic damage, VA was measured with either Landolt or Snellen charts. Uncorrected and best corrected VA was measured at a 0.4-m distance for near vision and >5-m distance for far vision. VA scores were analyzed through the calculation of weighted average logMAR (WMAR). 31 32 The numerator of the VA score was divided by the denominator, and the base 10 logarithm of the result was calculated. WMAR was then used to summarize the acuity data from both eyes in one score giving a 0.75 weighting to the better eye and a 0.25 weighting to the worse eye. 
In 43 patients, reading speed was measured with German-language Radner reading charts. 33  
Statistical Analyses
Comparisons of NEI-VFQ and SF-36 scores of the postchiasmatic sample to reference samples reported in other studies were calculated with the one-sample Wilcoxon test. NEI-VFQ results were compared to a healthy German reference group (n = 360) 22 and a small sample of postchiasmatic-lesioned patients (n = 33) investigated by Papageorgiou et al. 6 To estimate the influence of VFL on QoL beyond the impact of brain injury, we compared SF-36 reference data of stroke patients with lesion ages of 1 and 6 months investigated by Ronning and Stavem 3 to SF-36 data of the patients with postchiasmatic lesions investigated in the present study. 
Mean NEI-VFQ and SF-36 composite and subscale scores were compared between groups using multivariate analyses of covariance with the factors (1) postchiasmatic lesion, with versus without hemispatial neglect, (2) topography of VFL (e.g., hemianopia versus quadrantanopia), (3) side of VFL (i.e., both sides versus left-side versus right-side, and (4) etiology (e.g., ischemia versus hemorrhage); and with the following continuous covariates (1) VA, (2) reading speed, (3) patient’s age, and (4) lesion age. The post hoc Tukey test was conducted for the topography and side of VFL factors with correction of the significance level by the number of factor levels. 
The influence of hemispatial neglect additionally to left-side hemianopic VFL was studied in a separate variance analysis of NEI-VFQ subscales applying a three folded grouping factor: (1) patients with left-side hemianopic VFL with superimposed hemispatial neglect symptoms, (2) patients with left-side hemianopic VFL without neglect, and (3) patients with right-side hemianopic VFL. The three groups were matched by age and VA. 
We correlated NEI-VFQ and SF-36 composite and subscale scores with visual field characteristics obtained by campimetry and perimetry by using partial correlation coefficients with age as the control variable. Multiple linear regression models were calculated for NEI-VFQ scales with VA and VFL in campimetry as independent variables. The influence of the patient’s age was again controlled for by including age as a third variable using forced entry inclusion in the regression models. B-values and confidence intervals were reported separately for each NEI-VFQ subscale. 
Results are displayed as the mean ± SD. Statistical analyses were performed with commercial software (SPSS ver. 15.0; SPSS, Chicago, IL). 
Results
Vision- and Health-Related QoL in Patients with Visual Field Defects after Postchiasmatic Damage Compared with That of Reference Groups
NEI-VFQ scores of patients with postchiasmatic VFL were lower than scores of a disease-free comparison group except for color vision (Table 1) . 22 Concerning the NEI-VFQ between-group differences of 10 points were defined to be clinically relevant. 20 21 Mean differences of more than 10 points in comparison to the healthy reference group were observed for each NEI-VFQ subscale except for ocular pain and color vision. There were more than 20 points difference when compared to the healthy reference group for the subscales general vision (25.3), near vision (27.1), distance vision (20.8), social functioning (20.6), mental health (28.1), role difficulties (38.6), dependency (27.2), and peripheral vision (46.1). The largest difference to the healthy reference group was observed for driving (64.9). 
We further compared the whole sample to another group of previously investigated patients with postchiasmatic damage. 6 The present sample had significantly lower NEI-VFQ scores than the postchiasmatic-lesioned reference group except for the subscales color vision (no difference between samples) and general health (Table 1) . In contrast to all other NEI-VFQ scales the general health rating of the present patient sample was significantly better than the postchiasmatic-lesioned sample of Papageorgiou et al. 6 Negative differences of more than 10 points were observed for near vision (11.8), distance vision (10.9), social functioning (13.0), mental health (15.7), role difficulties (20.9), dependency (20.5), and peripheral vision (20.2). 
In a second group comparison (Table 2)health-related QoL measured with the SF-36 was compared between postchiasmatic-lesioned patients and stroke patients with lesion ages of 1 or 6 months from Ronning and Stavem. 3 Except for the subscale emotional well-being, patients with postchiasmatic lesions showed significant better SF-36 scores than did stroke patients with a lesion age of 1 month. 
The SF-36 scores of stroke patients with 6-month lesions were comparable to the ones of the postchiasmatic-lesioned group for the subcales general health perceptions and vitality (no significant differences between samples). The physical component score was significantly better in the postchiasmatic sample than in stroke patients with lesion ages of 6 months. This difference is due to better scores in the postchiasmatic group in the subscales bodily pain (7.8) and physical functioning (3.1). Opposite to the trend for better scores in the postchiasmatic group, these patients had a 15.3-point lower score in the subscale role limitations due to physical problems, which caused the difference in the physical component score (only 1.7 points) to be less pronounced than expected. 
The postchiasmatic group had a 5.2-point worse SF-36 mental component score than stroke patients 6 months after the lesion, with large differences in the subscales social functioning (9.6), emotional well-being (5.3), and role limitations due to emotional problems (20.0). 
Variables Influencing Vision-Related QoL in Patients with Visual Field Defects after Postchiasmatic Damage
Table 3displays relevant factors (presence of neglect, topography of VFL, side of VFL, and etiology) and covariates (VA, reading speed, age, and lesion age) that were hypothesized to influence vision-related QoL. The factor presence of neglect influenced the NEI-VFQ scales general health and mental health (P < 0.05). Differences in the subscales general vision, distance vision, and driving tended to reach significance (P < 0.1). A detailed analysis of the influence of comorbid hemispatial neglect on QoL in postchiasmatic lesioned patients is reported later (next section). 
The factor topography of the VFL influenced each vision-related subscale of the NEI-VFQ except the general health and ocular pain estimates (Table 3) . Table 4shows post hoc comparisons between patient groups with different topographies. In Table 4the topographies are ordered by the remaining intact visual field size (i.e., detected stimuli in the central visual field measured by computer campimetry): scotoma, quadrantanopia, incomplete hemianopia, complete hemianopia, visual field loss in three quadrants, diffuse visual field loss, and tunnel vision. Post hoc comparisons revealed only positive NEI-VFQ scale differences between topography types with larger remaining visual field size minus topography types with smaller visual fields. For instance, patients with scotoma rated their peripheral vision 50 points better than did patients with tunnel vision. Compared with complete hemianopics, patients with incomplete hemianopia had approximately 10 point better scores for the subscales near vision, distance vision, and color vision. Patients with quadrantanopia were significantly better than complete hemianopics in six subscales as well as the composite score. 
The factor side of the VFL also had a significant influence on some NEI-VFQ subscales, especially near and distance vision, social functioning and color vision (Table 3) . Post hoc comparisons between patient groups with only left, only right, and bilateral VFL are shown in Table 5 . Scores for patients with bilateral VFL were significantly lower in several scales than for patients with VFL on only one side. The composite score of patients with left VFL as well as right VFL was about 9 points higher than that of patients with bilateral VFL. 
The factor etiology of the lesion affected only the scales general health and ocular pain (Table 3) . The general health score was nearly 10 points higher for tumor than for ischemic (P < 0.05) as well as hemorrhagic infarctions (P < 0.1). 
VA, reading speed, patients’ age, and lesion age were tested as continuous covariates on their influence on NEI-VFQ results (Table 3) . VA and reading speed were related to vision-related QoL estimates except for the NEI-VFQ scores general health, ocular pain, and peripheral vision. The patients’ age also affected some scale scores. However, there was an intercorrelation of age with near VA (r = −0.24; P = 0.003; n = 153) and far VA (r = −0.26; P = 0.002; n = 133). NEI-VFQ scores were lower in patients with higher age (correlation with NEI-VFQ composite score, r = −0.21; P < 0.0001; n = 312). Therefore, age was considered as a control variable in partial correlation and multiple linear regression analyses. The lesion age influenced only the subscale role difficulties (Table 3)
The Influence of Comorbid Hemispatial Neglect on Vision-Related QoL in Patients with Postchiasmatic Lesions
Hemispatial neglect had a significant influence on the subscales general health and mental health when patients with neglect (n = 35) were compared to patients without neglect (n = 277; Table 3 ). 
In a more detailed analysis, one neglect patient was excluded from analysis because he showed a rightward neglect. NEI-VFQ scores of 34 patients with left-side VFL and associated hemispatial neglect were compared to matched patients with unilateral left- and right-side VFL without neglect (Fig. 2) . There were no differences between the three groups concerning age and VA. 
Neglect patients rated their general health 13.5 points worse than did those with left-side VFL without neglect and 8.6 points worse than patients with right-side VFL without neglect (P < 0.05). QoL estimates of reduced mental health due to vision problems and peripheral vision were significantly higher in neglect patients than in patients with VFL only. A trend for higher QoL ratings in neglect patients was observed for the subscales general vision, distance activities, and driving (P < 0.1). The largest difference (∼20 points) between neglect patients and patients with unilateral left- and right-side VFL was found for the driving subscale. 
Postchiasmatic Visual Field Loss and QoL
There were weak but highly significant correlations between several parameters of computer campimetry and the NEI-VFQ composite score. Positive correlations with the NEI-VFQ composite score were found with stimulus detection and fixation accuracy as well as with the area of sparing within the affected hemifield (Fig. 3) . Patients with a large intact visual field, high fixation accuracy and a large area of sparing within the affected hemifield had higher NEI-VFQ composite scores. 
Larger visual field defect sizes measured with computer campimetry were correlated with lower NEI-VFQ composite scores (r = −0.28; P < 0.0001). 
We further calculated partial correlation coefficients between QoL estimates (NEI-VFQ and SF-36 results) and VA and central visual field size in campimetry when the influence of patient’s age was adjusted for (Tables 6 7) . Both VA and VFL were significantly correlated with NEI-VFQ scores (Table 6)but not with SF-36 scores (Table 7) . It was then analyzed which mean NEI-VFQ differences can be expected with reduced VA and central visual field size in campimetry. For this purpose B-values and confidence intervals were calculated with linear regression analyses separately for each NEI-VFQ subscale using three independent variables: VFL (visual field defect size in campimetry), VA, and age (Table 8) . Regression functions for SF-36 scores were not established because VA and VFL had no impact on SF-36 scores when age was considered as a control variable (Table 7)
Because 1% differences in visual field size have no clinical relevance, B-values were multiplied by factor 10. Thus, Table 8shows expected reductions of NEI-VFQ results with 10% losses of visual field size and VA. All B-values and most of their confidence intervals for VFL were negative, indicating that increased VFL was associated with decreased vision-related QoL. Conversely, B-values for VA were positive. NEI-VFQ scores also declined with higher age as indicated by negative B-values. 
Because the regression analyses were performed with values of the central visual field, we also correlated QoL results with perimetry results that included the peripheral visual field. Again partial correlation coefficients were calculated with age and VA as control variables. Whereas there were moderate to high correlations between NEI-VFQ scores and VFL in perimetry (Table 9) , there were no significant correlations between SF-36 and VFL. Correlations between VFL of the eye with the larger lesion were slightly higher than correlations with VFL of the eye with the smaller lesion. 
Further Correlations of Visual Field Parameters and QoL
Slower reaction times on light stimuli in the campimetric visual field test were correlated with lower NEI-VFQ composite scores (r = −0.30; P < 0.0001). Mean reaction time in computer campimetry also correlated negatively with the SF-36 scales and component scores—highly significant for the physical component score (r = −0.24; P < 0.0001) and the scales physical functioning (r = −0.33; P < 0.0001), role limitations due to physical problems (r = −0.23; P < 0.0001), vitality (r = −0.22; P < 0.0001), social functioning (r = −0.27; P < 0.0001) and role limitations due to emotional problems (r = −0.20; P < 0.001). Lower but still significant correlations between reaction times and SF-36 scales were found for the mental component score (r = −0.15; P < 0.05), bodily pain (r = −0.13; P < 0.05), and emotional well-being (r = −0.13; P < 0.05). 
Fixation accuracy correlated weak but highly significant with the physical component score (r = 0.27; P < 0.0001) and the scales physical functioning (r = 0.29; P < 0.0001), role limitations due to physical problems (r = 0.24; P < 0.0001), bodily pain (r = 0.22; P < 0.0001), and vitality (r = 0.16; P < 0.0001). Further positive correlations of fixation accuracy were found with the scales social functioning (r = 0.15) and role limitations due to emotional problems (r = 0.14) both at a significance level of P < 0.05. 
Discussion
The results of the present study demonstrate a clear difference in vision-related QoL measured by NEI-VFQ scores between patients with postchiasmatic VFL and a healthy reference group (Table 1) . 22 The investigated 312 patients suffered the most from impaired peripheral vision, followed by impaired general vision, and role difficulties, as well as low mental health. The patients also reported more problems with driving, reduced distance vision as well as limited social functioning. In conclusion, patients with postchiasmatic lesions had marked impairments in their vision-related QoL, as shown previously. 6 7  
There were even lower NEI-VFQ scores in the investigated sample when compared with the 33 patients with postchiasmatic lesions of Papageorgiou et al., 6 except for a slightly better general health. Different lesion ages cannot account for this finding because the mean lesion age of both studies was approximately 2.7 years. It is possible that the different sample sizes between both studies led to a specific selection bias and an overestimation of vision-specific QoL in the sample in Papageorgiou et al. The present study with a larger sample size presumably corresponds more clearly to the clinical situation. 
However, it is possible that patients who were going to participate in neurovisual rehabilitation (which was the case in a subsample of the present study) rated their losses of visual functions as being more severe or indeed had larger VFL. Therefore, we subdivided our sample into treated versus untreated patients and compared these groups. This subdivision revealed no significant impact of “intention to treat” on NEI-VFQ scores and visual field variables which were measured before training. Treatment related effects on vision-related QoL in a subset of patients of the present sample have been described elsewhere. 7  
We further compared SF-36 scores (i.e., general health-related QoL) in the postchiasmatic patient group with those of stroke patients with lesions of different ages (Table 2) . 3 The present sample of patients with postchiasmatic lesions had less diminished health-related QoL than stroke patients with a lesion age of 1 month. But in comparison to stroke patients with lesion ages of 6 months, those with postchiasmatic lesions had worse health-related QoL in the SF-36 scales role limitations due to physical and due to emotional problems. Thus, although the postchiasmatic patient group also had lesion ages beyond 6 months, these patients mentioned greater problems in their role functions than did stroke patients in general. This result confirms the negative effect of VFL on role functions, as was also shown with the NEI-VFQ. 
In a multiple analysis of covariance, the influence of the factors neglect, topography of VFL, side of VFL, and etiology as well as of the continuous covariates VA, reading speed, and patients’ and lesion age was assessed (Table 3)
Presence of neglect symptoms influenced NEI-VFQ estimates less than expected (Fig. 2) . Patients in the neglect group rated their general health worse than those with right-side and left-side VFL without neglect, presumably because of additional nonvisual impairments. The three groups were matched by age and VA. Thus, these variables cannot account for group differences. However, in contrast to a worse general health rating, vision-targeted scales such as mental health, peripheral vision, general vision, distance vision, and driving scores were slightly higher for the neglect group, which appears consequential since neglect patients are known to underestimate their deficits. This effect was also observed for the composite score, which was significantly better in neglect patients than in patients with right-side and left-side hemianopic VFL without neglect. However, neglect patients did not differ from both groups concerning the half of the NEI-VFQ subscales (ocular pain, near vision, social functioning, role difficulties, dependency, and color vision). Concerning these subscales they seem to be aware of their visual dysfunctions without the expected overestimation. The rather realistic description of vision-specific problems in the neglect group with postchiasmatic VFL could be the result of social progresses such as repeated feedback of (spatial) vision problems by relatives and therapists. Normally, postchiasmatic patients without neglect do not receive this kind of feedback because these patients are more likely able to compensate for their visual field loss. 34  
Two further grouping factors—topography and side of VFL—determined the extent of the self-reported visual impairment in NEI-VFQ scales. Post hoc comparisons for both factors revealed significant differences between many NEI-VFQ subscales (Tables 4 5) . NEI-VFQ score differences between topography types were observed for all subscales except general health and ocular pain. Only positive NEI-VFQ score differences were observed because post hoc comparisons were systematically conducted always comparing topography types with larger remaining visual field size minus topography types with smaller remaining visual field size. This regularity already shows at the level of topographies that larger VFL is associated with worse self-evaluated visual functioning. For instance, tunnel vision, which had the largest VFL compared with the other topographies, was associated with restrictions in the peripheral visual field. The NEI-VFQ score differences between topographies confirms the content validity of the questionnaire. 
Post hoc comparisons for different sides of VFL revealed that bilateral VFL was accompanied by lower vision-related QoL estimates than unilateral (left or right) VFL. This result confirms prior findings by other authors who did not focus on postchiasmatic VFL and used mean deviation scores in perimetry to determine the severity of VFL. 35 36  
The etiology of the lesion influenced only the NEI-VFQ scores for general health and ocular pain and was therefore presumably unrelated to self-reported visual impairment. 
In addition, several covariates influenced NEI-VFQ results. VA, reading speed, and patients’ age were clearly associated with vision-related QoL, whereas lesion age did not play a major role (a significant influence was found only for the scale role difficulties). According to Franke et al. 37 the psychological impact of visual impairment in ophthalmic patients depended mainly on VA and age—elderly patients (between 70 and 79 years) and very old patients (between 80 and 93 years) suffered the most from low global and vision-specific quality of life. As our study shows, this is also true for patients with VFL. 
VFL was significantly related to NEI-VFQ ratings and thus to vision-related QoL, although there were only weak correlations with campimetry results (Fig. 3)and weak to moderate correlations with perimetry results (Table 9) . The correlations with VFL in perimetry were presumably slightly higher because perimetry results covered the whole visual field in contrast to computer campimetry, which measured only the central visual field. 
Although the NEI-VFQ was not designed to measure vision-related QoL in patients with postchiasmatic lesions but in patients with ophthalmic conditions, 19 21 the present study adds evidence that the questionnaire is also useful in patients with VFL after postchiasmatic lesions to the visual pathway. 6 7 The usefulness of the NEI-VFQ was also shown in a small sample of patients with prechiasmatic lesion who had multiple sclerosis. 38 In this prechiasmatic group the Spearman rank correlation coefficient between the NEI-VFQ composite score and visual field size was r = 0.53 (P = 0.003). 
When VA and VFL were correlated with QoL results with influence of age adjusted for only vision-related QoL measured with the NEI-VFQ was significantly associated (Table 6) . Partial correlations with SF-36 results for health-related QoL were low and not significant (Table 7) . Therefore multiple linear regression with VA and VFL as independent variables was calculated only for NEI-VFQ subscales (Table 8) . Linear regression models with VA and VFL as independent variables and NEI-VFQ scores as dependent variables revealed clear clinical relevance of the NEI-VFQ in estimating vision-related QoL. VA, VFL, and age were significantly related to and equally contributed to each NEI-VFQ score except for ocular pain (no regression model), general vision (influenced only by VA and age), and peripheral vision (influenced only by the extent of VFL). 
Beyond the general conclusion that VFL influences subjective vision-related QoL, we further wished to study whether the size of macular sparing within the affected hemifield has a positive influence on NEI-VFQ scores which was shown previously. 6 The value for the area of sparing differed between the present study (static campimetric measurement, see Fig. 1 ) and Papageorgiou et al. 6 (kinetic perimetric measurement). In the present study, the correlation of the NEI-VFQ composite score and area of sparing was lower but still significant (Fig. 3)
In summary, the use of standardized vision-related QoL instruments to measure the functional visual status of patients is an approach that is gaining popularity. Especially the NEI-VFQ is a valuable measure resulting in estimates of self-reported vision-related QoL which reflects not only the degree of VFL but also shows relations to its topography. In postchiasmatic patients subjective ratings of the patients’ visual status should be used with objective clinical measures to monitor individual patient progress in clinical settings and clinical trials. In addition to VA, especially perimetry results should be considered when trying to explain variance of NEI-VFQ results in patients with VFL due to postchiasmatic lesions of the visual pathway. 
 
Figure 1.
 
Visual field measures for correlation with QoL ratings were derived from monocular standard automated perimetry and binocular computer campimetry. Whereas perimetry charts included the periphery of the visual field, computer campimetry covered the visual field only up to ±16° vertically and ±21.5° horizontally. The extent of VFL was calculated for both visual field measures. In perimetry, VFL refers to absolute defects (%)—that is, positions where the stimulus was not detected even when presented with maximum luminance. In the campimetric visual field test, VFL corresponds to the number of black spots (%). The area of sparing within the affected hemifield was calculated based on campimetry results. Therefore, the ratio of intact positions (white spots in %) within the central 5° was calculated in the affected half-field only.
Figure 1.
 
Visual field measures for correlation with QoL ratings were derived from monocular standard automated perimetry and binocular computer campimetry. Whereas perimetry charts included the periphery of the visual field, computer campimetry covered the visual field only up to ±16° vertically and ±21.5° horizontally. The extent of VFL was calculated for both visual field measures. In perimetry, VFL refers to absolute defects (%)—that is, positions where the stimulus was not detected even when presented with maximum luminance. In the campimetric visual field test, VFL corresponds to the number of black spots (%). The area of sparing within the affected hemifield was calculated based on campimetry results. Therefore, the ratio of intact positions (white spots in %) within the central 5° was calculated in the affected half-field only.
Table 1.
 
NEI-VFQ Subscale Scores in Patients with Postchiasmatic Lesions Compared with Reference Groups
Table 1.
 
NEI-VFQ Subscale Scores in Patients with Postchiasmatic Lesions Compared with Reference Groups
NEI-VFQ Patients with Postchiasmatic Lesions (Present Study) (n = 312) Reference Group with Postchiasmatic Lesions (n = 33)* Healthy Reference Group (n = 360), † One-Sample Wilcoxon Rank Test
Postchiasmatic Lesion (Present Study) versus Reference Postchiasmatic Lesion* Postchiasmatic Lesion (Present Study) versus Healthy Reference, †
NEI-VFQ composite score of 12 subscales (n = 312) 63.9 , ‡ 90.6 Z = −15.2; P < 0.0001
NEI-VFQ composite score of 11 subscales without general health (n = 312) 65.4 77.1 , ‡ Z = −9.8; P < 0.0001
1. General health (n = 305) 49.5 44.7 69.4 Z = 4.0; P < 0.0001 Z = −12.5; P < 0.0001
2. General vision (n = 303) 57.3 65.5 82.6 Z = −7.5; P < 0.0001 Z = −14.8; P < 0.0001
3. Ocular pain (n = 306) 86.2 92.0 89.2 Z = −2.1; P < 0.05 Z = −2.1; P < 0.05
4. Near vision (n = 312) 66.2 78.0 93.3 Z = −7.2; P < 0.0001 Z = −14.4; P < 0.0001
5. Distance vision (n = 312) 73.9 84.8 94.7 Z = −6.6; P < 0.0001 Z = −13.6; P < 0.0001
6. Social functioning (n = 312) 76.0 89.0 96.6 Z = −8.8; P < 0.0001 Z = −13.5; P < 0.0001
7. Mental health (n = 304) 62.1 77.8 90.2 Z = −9.3; P < 0.0001 Z = −14.2; P < 0.0001
8. Role difficulties (n = 300) 53.0 73.9 91.6 Z = −11.7; P < 0.0001 Z = −14.9; P < 0.0001
9. Dependency (n = 302) 69.4 89.9 96.6 Z = −8.1; P < 0.0001 Z = −11.1; P < 0.0001
10. Driving (n = 249) 27.5 32.6 92.4 Z = −2.3; P < 0.05 Z = −13.8; P < 0.0001
11. Color vision (n = 304) 88.2 94.7 97.0 Z = −0.4; NS Z = −0.4; NS
12. Peripheral vision (n = 309) 49.5 69.7 95.6 Z = −10.9; P < 0.0001 Z = −15.1; P < 0.0001
Table 2.
 
SF-36 Subscale Scores in Patients with Postchiasmatic Lesions Compared with Stroke Patients 1 and 6 Months after Stroke
Table 2.
 
SF-36 Subscale Scores in Patients with Postchiasmatic Lesions Compared with Stroke Patients 1 and 6 Months after Stroke
SF-36 Subscale Patients with Postchiasmatic Lesions (Present Study) (n = 273) Stroke Reference Group, 1 Month after Lesion (n = 179)* Stroke Reference Group, 6 Months after Lesion (n = 140)* One-Sample Wilcoxon Rank Test
Postchiasmatic Lesion (Present Study) versus Stroke 1 Month after Lesion Postchiasmatic Patients (Present Study) versus Stroke Patients 6 Months after Lesion
Physical functioning (n = 270) 66.2 48.4 63.1 Z = 8.2; P < 0.0001 Z = 2.5; P < 0.05
Role limitations due to physical problems (n = 269) 46.8 17.6 62.1 Z = 7.9; P < 0.0001 Z = −5.0; P < 0.0001
Bodily pain (n = 270) 78.7 63.9 70.9 Z = 8.1; P < 0.0001 Z = 4.4; P < 0.0001
General health perceptions (n = 270) 57.5 53.6 59.1 Z = 2.6; P < 0.01 Z = −0.9; NS
Vitality (n = 272) 53.8 41.8 52.7 Z = 8.9; P < 0.0001 Z = 0.5; NS
Social functioning (n = 272) 75.4 61.6 85.0 Z = 9.1; P < 0.0001 Z = −3.9; P < 0.0001
Role limitations due to emotional problems (n = 262) 70.9 34.6 90.9 Z = 11.4; P < 0.0001 Z = −2.3; P < 0.05
Emotional well-being (n = 272) 66.7 67.7 72.0 Z = −0.6; NS Z = −3.4; P < 0.001
Physical component score (n = 260) 43.5 36.1 41.8 Z = 9.1; P < 0.0001 Z = 2.8; P < 0.01
Mental component score (n = 260) 47.8 43.3 53.0 Z = 6.1; P < 0.0001 Z = −5.4; P < 0.0001
Table 3.
 
F-values and Statistical Significance of Grouping Factors and Supplementary Continuous Independent Variables on NEI-VFQ Subscales in a Multiple Analysis of Covariance
Table 3.
 
F-values and Statistical Significance of Grouping Factors and Supplementary Continuous Independent Variables on NEI-VFQ Subscales in a Multiple Analysis of Covariance
NEI-VFQ Subscale Factors Covariates
Neglect (df = 1) Topography of VFL (df = 6) Side of VFL (df = 2) Etiology (df = 3) VA (df = 1) Reading Speed (df = 1) Patient’s Age (df = 1) Lesion Age (df = 1)
NEI-VFQ composite score of 12 subscales (n = 312) 1.6 5.9, *** 3.8* 0.4 19.8, *** 9.0, ** 5.7* 2.0
NEI-VFQ composite score of 11 subscales without general health (n = 312) 3.0, † 6.1, *** 4.5* 0.2 19.7, *** 9.7, ** 5.9* 1.9
1. General health (n = 305) 15.3, *** 1.7 0.8 2.9* 3.5, † 0.2 0.5 1.3
2. General vision (n = 303) 3.1, † 2.6* 2.8* 0.9 15.4, *** 5.3 1.6 0.5
3. Ocular pain (n = 306) 0.2 1.4 0.3 2.1* 0.1 0.0 3.0, † 0.0
4. Near vision (n = 312) 0.5 5.4, *** 7.7, *** 0.8 33.1, *** 15.1, *** 15.6, *** 1.3
5. Distance vision (n = 312) 3.1, † 6.5, *** 8.1, *** 0.8 25.6, *** 5.4* 7.6, ** 0.3
6. Social functioning (n = 312) 0.9 5.8, *** 6.8, *** 0.5 22.5, *** 5.9* 9.9, ** 0.0
7. Mental health (n = 304) 8.1, ** 2.2* 0.8 1.0 15.2, *** 5.1* 0.4 1.4
8. Role difficulties (n = 300) 0.0 4.5, *** 1.4 1.1 6.9, ** 2.8 2.7, † 4.0*
9. Dependency (n = 302) 0.5 3.4, ** 4.0* 0.9 11.8, *** 7.2* 2.8, † 2.3
10. Driving (n = 249) 3.7, † 3.9, ** 0.8 0.6 4.7* 5.6* 0.4 2.4
11. Color vision (n = 304) 0.0 7.7, *** 8.3, *** 0.9 7.9, ** 13.4, *** 10.8, *** 0.3
12. Peripheral vision (n = 309) 1.0 7.5, *** 2.2, † 0.7 2.4 1.5 0.0 0.6
Table 4.
 
Post Hoc Comparisons for the Grouping Factor Topography of VFL
Table 4.
 
Post Hoc Comparisons for the Grouping Factor Topography of VFL
Comparison of VFL Topography Types NEI-VFQ Score Differences between Topography Types
Composite Score 1 2 3 4 5 6 7 8 9 10 11 12
Scotoma (94.5% ± 5.6%)
 Complete hemianopia 33.5
 Diffuse VFL 23.8
 Tunnel vision 37.5 50.0
Quadrantanopia (72.9% ± 13.1%)
 Incomplete hemianopia 19.8 16.5
 Complete hemianopia 11.8 12.9 12.3 12.3 15.0 32.3 24.3
 Diffuse VFL 15.0 12.2 18.3 17.5 19.2 16.8 19.2 26.4 17.1 16.4
 Tunnel vision 24.4 24.2 29.5 32.2 26.2 41.8 30.8 40.9
Incomplete hemianopia (60.7% ± 10.9%)
 Complete hemianopia 7.2 11.2 9.7 9.5
 Tunnel vision 19.8 22.5 26.9 27.2 20.5 31.6 24.4
 Diffuse VFL 10.4 16.6 14.8 14.2 12.0 17.3 18.0
Complete hemianopia (53.2% ± 8.1%)
 Tunnel vision 22.1
VFL in three quadrants (50.7% ± 15.9%)
 Tunnel vision 20.3 27.2 28.9 30.8 32.1
 Diffuse VFL 17.2
Diffuse VFL (46.8% ± 20.9%)
 Tunnel vision (10.4% ± 4.6%) 24.4
Table 5.
 
Post Hoc Comparisons for the Grouping Factor Side of VFL
Table 5.
 
Post Hoc Comparisons for the Grouping Factor Side of VFL
Comparison of Different Sides of VFL NEI-VFQ Score Differences between Topography Types
Composite Score 1 2 3 4 5 6 7 8 9 10 11 12
VFL left versus bilateral VFL 8.6 7.7 12.1 11.4 11.6 11.9
VFL right versus bilateral VFL 8.8 13.3 12.7 14.3 9.8 17.0
Figure 2.
 
Comparisons of NEI-VFQ scores (mean ± SD) of patients with VFL after postchiasmatic damage without evidence of hemispatial neglect compared with 34 patients with left-side hemianopic VFL and associated neglect symptoms. There were no differences between the three groups with respect to age and VA (both F < 0.5). The groups with and without neglect differed according to their general health and mental health ratings. (*)P < 0.1; *P < 0.05; **P < 0.01.
Figure 2.
 
Comparisons of NEI-VFQ scores (mean ± SD) of patients with VFL after postchiasmatic damage without evidence of hemispatial neglect compared with 34 patients with left-side hemianopic VFL and associated neglect symptoms. There were no differences between the three groups with respect to age and VA (both F < 0.5). The groups with and without neglect differed according to their general health and mental health ratings. (*)P < 0.1; *P < 0.05; **P < 0.01.
Figure 3.
 
Scatterplot of computer campimetry performance (detected stimuli, i.e., intact visual field size; fixation accuracy, and area of sparing within the affected hemifield, i.e., ratio of intact field within central 5°) by the NEI-VFQ composite score.
Figure 3.
 
Scatterplot of computer campimetry performance (detected stimuli, i.e., intact visual field size; fixation accuracy, and area of sparing within the affected hemifield, i.e., ratio of intact field within central 5°) by the NEI-VFQ composite score.
Table 6.
 
Partial Correlation Coefficients Controlled for Age between NEI-VFQ Results and the Two Impairment Variables VA and VFL
Table 6.
 
Partial Correlation Coefficients Controlled for Age between NEI-VFQ Results and the Two Impairment Variables VA and VFL
NEI-VFQ VFL VA
NEI-VFQ composite score of 11 subscales without general health (n = 152) −0.44, *** 0.40, ***
1. General health (n = 149) −0.10 (NS) 0.19, †
2. General vision (n = 147) −0.38, *** 0.37, ***
3. Ocular pain (n = 147) −0.03 (NS) 0.01 (NS)
4. Near vision (n = 152) −0.38, *** 0.49, ***
5. Distance vision (n = 152) −0.37, *** 0.43, ***
6. Social functioning (n = 152) −0.32, *** 0.40, ***
7. Mental health (n = 147) −0.45, *** 0.36, ***
8. Role difficulties (n = 142) −0.38, *** 0.25*
9. Dependency (n = 147) −0.38, *** 0.30, **
10. Driving (n = 116) −0.23* 0.21*
11. Color vision (n = 148) −0.31, ** 0.25*
12. Peripheral vision (n = 150) −0.34, ** 0.17, †
Table 7.
 
Partial Correlation Coefficients Controlled for Age between SF-36 Results and the Two Impairment Variables VA and VFL
Table 7.
 
Partial Correlation Coefficients Controlled for Age between SF-36 Results and the Two Impairment Variables VA and VFL
SF-36 VFL VA
1. Physical functioning (n = 130) 0.12 0.14
2. Role limitations due to physical problems (n = 128) 0.02 0.13
3. Bodily pain (n = 130) 0.04 0.14
4. General health perceptions (n = 130) 0.16 0.02
5. Vitality (n = 130) 0.01 0.12
6. Social functioning (n = 130) 0.03 0.16
7. Role limitations due to emotional problems (n = 127) 0.07 0.07
8. Emotional well-being (n = 130) 0.03 0.18
9. Physical component score (n = 126) 0.08 0.15
10. Mental component score (n = 126) 0.01 0.04
Table 8.
 
Multivariate Regression Analyses for each NEI-VFQ Subscale and Composite Scores
Table 8.
 
Multivariate Regression Analyses for each NEI-VFQ Subscale and Composite Scores
NEI-VFQ Independent Variables B (CI of B) Significance Level
NEI-VFQ composite score of 12 subscales (n = 152) VFL −2.6 (−3.9 to −1.2) , ***
VA 2.9 (1.5 to 4.3) , ***
Age −2.2 (−3.7 to −0.6) , **
NEI-VFQ composite score of 11 subscales without general health (n = 152) VFL −2.8 (−4.3 to −1.4) , ***
VA 2.9 (1.4 to 4.3) , ***
Age −2.2 (−3.8 to −0.1) *
1. General health (n = 149) VFL — — NS
VA 2.8 (1.0 to 4.6) , **
Age −1.9 (−3.9 to 0.3) , †
2. General vision (n = 147) VFL −2.4 (−3.9 to −0.9) , **
VA 2.2 (0.7 to 3.7) , **
Age −1.7 (−3.5 to 0.0) , †
3. Ocular pain (n = 147) VFL — — NS
VA — — NS
Age — — NS
4. Near vision (n = 152) VFL −1.9 (−3.7 to −0.1) *
VA 5.3 (3.5 to 7.1) , ***
Age −2.3 (−4.3 to −0.2) *
5. Distance vision (n = 152) VFL −3.2 (−4.9 to −1.4) , ***
VA 3.5 (1.7 to 5.3) , ***
Age −2.3 (−4.3 to −0.3) *
6. Social functioning (n = 152) VFL −2.7 (−4.6 to −0.8) , **
VA 3.7 (1.8 to 5.7) , ***
Age −1.9 (−4.2 to 0.3) , †
7. Mental health (n = 147) VFL −3.3 (−5.4 to −1.3) , **
VA 3.5 (1.5 to 5.6) , **
Age −2.3 (−4.7 to 0.0) , †
8. Role difficulties (n = 142) VFL −3.2 (−5.4 to −1.0) , **
VA 2.9 (0.8 to 5.1) , **
Age −2.4 (−4.8 to 0.1) , †
9. Dependency (n = 147) VFL −4.1 (−6.8 to −1.4) , **
VA 4.5 (1.8 to 7.3) , **
Age −4.2 (−7.3 to −1.0) , **
10. Driving (n = 116) VFL −3.3 (−7.4 to 0.9) , †
VA 3.4 (−0.5 to 7.4) , †
Age — — NS
11. Color vision (n = 148) VFL −2.4 (−4.3 to −0.5) *
VA 1.9 (0.0 to 3.8) , †
Age −4.1 (−6.2 to −1.9) , ***
12. Peripheral vision (n = 150) VFL −4.1 (−6.4 to −1.7) , ***
VA — — NS
Age — — NS
Table 9.
 
Partial Correlation Coefficients Controlled for Age and VA between NEI-VFQ Scores and Visual Field Defect Size as Measured by 90° Standard Automated Perimetry in Patients with Postchiasmatic Lesions
Table 9.
 
Partial Correlation Coefficients Controlled for Age and VA between NEI-VFQ Scores and Visual Field Defect Size as Measured by 90° Standard Automated Perimetry in Patients with Postchiasmatic Lesions
NEI-VFQ Number of Absolute Defects in %
Eye with Larger VFL Eye with Smaller VFL
NEI-VFQ composite score of 11 subscales without general health (n = 148) −0.48, *** −0.40, ***
1. General health (n = 145) −0.08 (NS) −0.12 (NS)
2. General vision (n = 144) −0.28, ** −0.18*
3. Ocular pain (n = 143) −0.03 (NS) 0.07 (NS)
4. Near vision (n = 148) −0.28, ** −0.31, ***
5. Distance vision (n = 148) −0.40, *** −0.37, ***
6. Social functioning (n = 148) −0.43, *** −0.42, ***
7. Mental health (n = 143) −0.26, ** −0.28, **
8. Role difficulties (n = 138) −0.46, *** −0.44, ***
9. Dependency (n = 143) −0.42, *** −0.41, ***
10. Driving (n = 114) −0.33, *** −0.31, **
11. Color vision (n = 144) −0.39, *** −0.41, ***
12. Peripheral vision (n = 146) −0.47, *** −0.44, ***
The authors thank Dorothee Schlüter (NovaVision AG, Magdeburg) for support in data collection; Siegfried Kropf (Institute of Biometry and Medical Informatics, Magdeburg) for mentoring in statistic and biometric questions; and Anja Lindig (Institute of Medical Psychology, Magdeburg) for careful assistance in the preparation of the manuscript. 
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Figure 1.
 
Visual field measures for correlation with QoL ratings were derived from monocular standard automated perimetry and binocular computer campimetry. Whereas perimetry charts included the periphery of the visual field, computer campimetry covered the visual field only up to ±16° vertically and ±21.5° horizontally. The extent of VFL was calculated for both visual field measures. In perimetry, VFL refers to absolute defects (%)—that is, positions where the stimulus was not detected even when presented with maximum luminance. In the campimetric visual field test, VFL corresponds to the number of black spots (%). The area of sparing within the affected hemifield was calculated based on campimetry results. Therefore, the ratio of intact positions (white spots in %) within the central 5° was calculated in the affected half-field only.
Figure 1.
 
Visual field measures for correlation with QoL ratings were derived from monocular standard automated perimetry and binocular computer campimetry. Whereas perimetry charts included the periphery of the visual field, computer campimetry covered the visual field only up to ±16° vertically and ±21.5° horizontally. The extent of VFL was calculated for both visual field measures. In perimetry, VFL refers to absolute defects (%)—that is, positions where the stimulus was not detected even when presented with maximum luminance. In the campimetric visual field test, VFL corresponds to the number of black spots (%). The area of sparing within the affected hemifield was calculated based on campimetry results. Therefore, the ratio of intact positions (white spots in %) within the central 5° was calculated in the affected half-field only.
Figure 2.
 
Comparisons of NEI-VFQ scores (mean ± SD) of patients with VFL after postchiasmatic damage without evidence of hemispatial neglect compared with 34 patients with left-side hemianopic VFL and associated neglect symptoms. There were no differences between the three groups with respect to age and VA (both F < 0.5). The groups with and without neglect differed according to their general health and mental health ratings. (*)P < 0.1; *P < 0.05; **P < 0.01.
Figure 2.
 
Comparisons of NEI-VFQ scores (mean ± SD) of patients with VFL after postchiasmatic damage without evidence of hemispatial neglect compared with 34 patients with left-side hemianopic VFL and associated neglect symptoms. There were no differences between the three groups with respect to age and VA (both F < 0.5). The groups with and without neglect differed according to their general health and mental health ratings. (*)P < 0.1; *P < 0.05; **P < 0.01.
Figure 3.
 
Scatterplot of computer campimetry performance (detected stimuli, i.e., intact visual field size; fixation accuracy, and area of sparing within the affected hemifield, i.e., ratio of intact field within central 5°) by the NEI-VFQ composite score.
Figure 3.
 
Scatterplot of computer campimetry performance (detected stimuli, i.e., intact visual field size; fixation accuracy, and area of sparing within the affected hemifield, i.e., ratio of intact field within central 5°) by the NEI-VFQ composite score.
Table 1.
 
NEI-VFQ Subscale Scores in Patients with Postchiasmatic Lesions Compared with Reference Groups
Table 1.
 
NEI-VFQ Subscale Scores in Patients with Postchiasmatic Lesions Compared with Reference Groups
NEI-VFQ Patients with Postchiasmatic Lesions (Present Study) (n = 312) Reference Group with Postchiasmatic Lesions (n = 33)* Healthy Reference Group (n = 360), † One-Sample Wilcoxon Rank Test
Postchiasmatic Lesion (Present Study) versus Reference Postchiasmatic Lesion* Postchiasmatic Lesion (Present Study) versus Healthy Reference, †
NEI-VFQ composite score of 12 subscales (n = 312) 63.9 , ‡ 90.6 Z = −15.2; P < 0.0001
NEI-VFQ composite score of 11 subscales without general health (n = 312) 65.4 77.1 , ‡ Z = −9.8; P < 0.0001
1. General health (n = 305) 49.5 44.7 69.4 Z = 4.0; P < 0.0001 Z = −12.5; P < 0.0001
2. General vision (n = 303) 57.3 65.5 82.6 Z = −7.5; P < 0.0001 Z = −14.8; P < 0.0001
3. Ocular pain (n = 306) 86.2 92.0 89.2 Z = −2.1; P < 0.05 Z = −2.1; P < 0.05
4. Near vision (n = 312) 66.2 78.0 93.3 Z = −7.2; P < 0.0001 Z = −14.4; P < 0.0001
5. Distance vision (n = 312) 73.9 84.8 94.7 Z = −6.6; P < 0.0001 Z = −13.6; P < 0.0001
6. Social functioning (n = 312) 76.0 89.0 96.6 Z = −8.8; P < 0.0001 Z = −13.5; P < 0.0001
7. Mental health (n = 304) 62.1 77.8 90.2 Z = −9.3; P < 0.0001 Z = −14.2; P < 0.0001
8. Role difficulties (n = 300) 53.0 73.9 91.6 Z = −11.7; P < 0.0001 Z = −14.9; P < 0.0001
9. Dependency (n = 302) 69.4 89.9 96.6 Z = −8.1; P < 0.0001 Z = −11.1; P < 0.0001
10. Driving (n = 249) 27.5 32.6 92.4 Z = −2.3; P < 0.05 Z = −13.8; P < 0.0001
11. Color vision (n = 304) 88.2 94.7 97.0 Z = −0.4; NS Z = −0.4; NS
12. Peripheral vision (n = 309) 49.5 69.7 95.6 Z = −10.9; P < 0.0001 Z = −15.1; P < 0.0001
Table 2.
 
SF-36 Subscale Scores in Patients with Postchiasmatic Lesions Compared with Stroke Patients 1 and 6 Months after Stroke
Table 2.
 
SF-36 Subscale Scores in Patients with Postchiasmatic Lesions Compared with Stroke Patients 1 and 6 Months after Stroke
SF-36 Subscale Patients with Postchiasmatic Lesions (Present Study) (n = 273) Stroke Reference Group, 1 Month after Lesion (n = 179)* Stroke Reference Group, 6 Months after Lesion (n = 140)* One-Sample Wilcoxon Rank Test
Postchiasmatic Lesion (Present Study) versus Stroke 1 Month after Lesion Postchiasmatic Patients (Present Study) versus Stroke Patients 6 Months after Lesion
Physical functioning (n = 270) 66.2 48.4 63.1 Z = 8.2; P < 0.0001 Z = 2.5; P < 0.05
Role limitations due to physical problems (n = 269) 46.8 17.6 62.1 Z = 7.9; P < 0.0001 Z = −5.0; P < 0.0001
Bodily pain (n = 270) 78.7 63.9 70.9 Z = 8.1; P < 0.0001 Z = 4.4; P < 0.0001
General health perceptions (n = 270) 57.5 53.6 59.1 Z = 2.6; P < 0.01 Z = −0.9; NS
Vitality (n = 272) 53.8 41.8 52.7 Z = 8.9; P < 0.0001 Z = 0.5; NS
Social functioning (n = 272) 75.4 61.6 85.0 Z = 9.1; P < 0.0001 Z = −3.9; P < 0.0001
Role limitations due to emotional problems (n = 262) 70.9 34.6 90.9 Z = 11.4; P < 0.0001 Z = −2.3; P < 0.05
Emotional well-being (n = 272) 66.7 67.7 72.0 Z = −0.6; NS Z = −3.4; P < 0.001
Physical component score (n = 260) 43.5 36.1 41.8 Z = 9.1; P < 0.0001 Z = 2.8; P < 0.01
Mental component score (n = 260) 47.8 43.3 53.0 Z = 6.1; P < 0.0001 Z = −5.4; P < 0.0001
Table 3.
 
F-values and Statistical Significance of Grouping Factors and Supplementary Continuous Independent Variables on NEI-VFQ Subscales in a Multiple Analysis of Covariance
Table 3.
 
F-values and Statistical Significance of Grouping Factors and Supplementary Continuous Independent Variables on NEI-VFQ Subscales in a Multiple Analysis of Covariance
NEI-VFQ Subscale Factors Covariates
Neglect (df = 1) Topography of VFL (df = 6) Side of VFL (df = 2) Etiology (df = 3) VA (df = 1) Reading Speed (df = 1) Patient’s Age (df = 1) Lesion Age (df = 1)
NEI-VFQ composite score of 12 subscales (n = 312) 1.6 5.9, *** 3.8* 0.4 19.8, *** 9.0, ** 5.7* 2.0
NEI-VFQ composite score of 11 subscales without general health (n = 312) 3.0, † 6.1, *** 4.5* 0.2 19.7, *** 9.7, ** 5.9* 1.9
1. General health (n = 305) 15.3, *** 1.7 0.8 2.9* 3.5, † 0.2 0.5 1.3
2. General vision (n = 303) 3.1, † 2.6* 2.8* 0.9 15.4, *** 5.3 1.6 0.5
3. Ocular pain (n = 306) 0.2 1.4 0.3 2.1* 0.1 0.0 3.0, † 0.0
4. Near vision (n = 312) 0.5 5.4, *** 7.7, *** 0.8 33.1, *** 15.1, *** 15.6, *** 1.3
5. Distance vision (n = 312) 3.1, † 6.5, *** 8.1, *** 0.8 25.6, *** 5.4* 7.6, ** 0.3
6. Social functioning (n = 312) 0.9 5.8, *** 6.8, *** 0.5 22.5, *** 5.9* 9.9, ** 0.0
7. Mental health (n = 304) 8.1, ** 2.2* 0.8 1.0 15.2, *** 5.1* 0.4 1.4
8. Role difficulties (n = 300) 0.0 4.5, *** 1.4 1.1 6.9, ** 2.8 2.7, † 4.0*
9. Dependency (n = 302) 0.5 3.4, ** 4.0* 0.9 11.8, *** 7.2* 2.8, † 2.3
10. Driving (n = 249) 3.7, † 3.9, ** 0.8 0.6 4.7* 5.6* 0.4 2.4
11. Color vision (n = 304) 0.0 7.7, *** 8.3, *** 0.9 7.9, ** 13.4, *** 10.8, *** 0.3
12. Peripheral vision (n = 309) 1.0 7.5, *** 2.2, † 0.7 2.4 1.5 0.0 0.6
Table 4.
 
Post Hoc Comparisons for the Grouping Factor Topography of VFL
Table 4.
 
Post Hoc Comparisons for the Grouping Factor Topography of VFL
Comparison of VFL Topography Types NEI-VFQ Score Differences between Topography Types
Composite Score 1 2 3 4 5 6 7 8 9 10 11 12
Scotoma (94.5% ± 5.6%)
 Complete hemianopia 33.5
 Diffuse VFL 23.8
 Tunnel vision 37.5 50.0
Quadrantanopia (72.9% ± 13.1%)
 Incomplete hemianopia 19.8 16.5
 Complete hemianopia 11.8 12.9 12.3 12.3 15.0 32.3 24.3
 Diffuse VFL 15.0 12.2 18.3 17.5 19.2 16.8 19.2 26.4 17.1 16.4
 Tunnel vision 24.4 24.2 29.5 32.2 26.2 41.8 30.8 40.9
Incomplete hemianopia (60.7% ± 10.9%)
 Complete hemianopia 7.2 11.2 9.7 9.5
 Tunnel vision 19.8 22.5 26.9 27.2 20.5 31.6 24.4
 Diffuse VFL 10.4 16.6 14.8 14.2 12.0 17.3 18.0
Complete hemianopia (53.2% ± 8.1%)
 Tunnel vision 22.1
VFL in three quadrants (50.7% ± 15.9%)
 Tunnel vision 20.3 27.2 28.9 30.8 32.1
 Diffuse VFL 17.2
Diffuse VFL (46.8% ± 20.9%)
 Tunnel vision (10.4% ± 4.6%) 24.4
Table 5.
 
Post Hoc Comparisons for the Grouping Factor Side of VFL
Table 5.
 
Post Hoc Comparisons for the Grouping Factor Side of VFL
Comparison of Different Sides of VFL NEI-VFQ Score Differences between Topography Types
Composite Score 1 2 3 4 5 6 7 8 9 10 11 12
VFL left versus bilateral VFL 8.6 7.7 12.1 11.4 11.6 11.9
VFL right versus bilateral VFL 8.8 13.3 12.7 14.3 9.8 17.0
Table 6.
 
Partial Correlation Coefficients Controlled for Age between NEI-VFQ Results and the Two Impairment Variables VA and VFL
Table 6.
 
Partial Correlation Coefficients Controlled for Age between NEI-VFQ Results and the Two Impairment Variables VA and VFL
NEI-VFQ VFL VA
NEI-VFQ composite score of 11 subscales without general health (n = 152) −0.44, *** 0.40, ***
1. General health (n = 149) −0.10 (NS) 0.19, †
2. General vision (n = 147) −0.38, *** 0.37, ***
3. Ocular pain (n = 147) −0.03 (NS) 0.01 (NS)
4. Near vision (n = 152) −0.38, *** 0.49, ***
5. Distance vision (n = 152) −0.37, *** 0.43, ***
6. Social functioning (n = 152) −0.32, *** 0.40, ***
7. Mental health (n = 147) −0.45, *** 0.36, ***
8. Role difficulties (n = 142) −0.38, *** 0.25*
9. Dependency (n = 147) −0.38, *** 0.30, **
10. Driving (n = 116) −0.23* 0.21*
11. Color vision (n = 148) −0.31, ** 0.25*
12. Peripheral vision (n = 150) −0.34, ** 0.17, †
Table 7.
 
Partial Correlation Coefficients Controlled for Age between SF-36 Results and the Two Impairment Variables VA and VFL
Table 7.
 
Partial Correlation Coefficients Controlled for Age between SF-36 Results and the Two Impairment Variables VA and VFL
SF-36 VFL VA
1. Physical functioning (n = 130) 0.12 0.14
2. Role limitations due to physical problems (n = 128) 0.02 0.13
3. Bodily pain (n = 130) 0.04 0.14
4. General health perceptions (n = 130) 0.16 0.02
5. Vitality (n = 130) 0.01 0.12
6. Social functioning (n = 130) 0.03 0.16
7. Role limitations due to emotional problems (n = 127) 0.07 0.07
8. Emotional well-being (n = 130) 0.03 0.18
9. Physical component score (n = 126) 0.08 0.15
10. Mental component score (n = 126) 0.01 0.04
Table 8.
 
Multivariate Regression Analyses for each NEI-VFQ Subscale and Composite Scores
Table 8.
 
Multivariate Regression Analyses for each NEI-VFQ Subscale and Composite Scores
NEI-VFQ Independent Variables B (CI of B) Significance Level
NEI-VFQ composite score of 12 subscales (n = 152) VFL −2.6 (−3.9 to −1.2) , ***
VA 2.9 (1.5 to 4.3) , ***
Age −2.2 (−3.7 to −0.6) , **
NEI-VFQ composite score of 11 subscales without general health (n = 152) VFL −2.8 (−4.3 to −1.4) , ***
VA 2.9 (1.4 to 4.3) , ***
Age −2.2 (−3.8 to −0.1) *
1. General health (n = 149) VFL — — NS
VA 2.8 (1.0 to 4.6) , **
Age −1.9 (−3.9 to 0.3) , †
2. General vision (n = 147) VFL −2.4 (−3.9 to −0.9) , **
VA 2.2 (0.7 to 3.7) , **
Age −1.7 (−3.5 to 0.0) , †
3. Ocular pain (n = 147) VFL — — NS
VA — — NS
Age — — NS
4. Near vision (n = 152) VFL −1.9 (−3.7 to −0.1) *
VA 5.3 (3.5 to 7.1) , ***
Age −2.3 (−4.3 to −0.2) *
5. Distance vision (n = 152) VFL −3.2 (−4.9 to −1.4) , ***
VA 3.5 (1.7 to 5.3) , ***
Age −2.3 (−4.3 to −0.3) *
6. Social functioning (n = 152) VFL −2.7 (−4.6 to −0.8) , **
VA 3.7 (1.8 to 5.7) , ***
Age −1.9 (−4.2 to 0.3) , †
7. Mental health (n = 147) VFL −3.3 (−5.4 to −1.3) , **
VA 3.5 (1.5 to 5.6) , **
Age −2.3 (−4.7 to 0.0) , †
8. Role difficulties (n = 142) VFL −3.2 (−5.4 to −1.0) , **
VA 2.9 (0.8 to 5.1) , **
Age −2.4 (−4.8 to 0.1) , †
9. Dependency (n = 147) VFL −4.1 (−6.8 to −1.4) , **
VA 4.5 (1.8 to 7.3) , **
Age −4.2 (−7.3 to −1.0) , **
10. Driving (n = 116) VFL −3.3 (−7.4 to 0.9) , †
VA 3.4 (−0.5 to 7.4) , †
Age — — NS
11. Color vision (n = 148) VFL −2.4 (−4.3 to −0.5) *
VA 1.9 (0.0 to 3.8) , †
Age −4.1 (−6.2 to −1.9) , ***
12. Peripheral vision (n = 150) VFL −4.1 (−6.4 to −1.7) , ***
VA — — NS
Age — — NS
Table 9.
 
Partial Correlation Coefficients Controlled for Age and VA between NEI-VFQ Scores and Visual Field Defect Size as Measured by 90° Standard Automated Perimetry in Patients with Postchiasmatic Lesions
Table 9.
 
Partial Correlation Coefficients Controlled for Age and VA between NEI-VFQ Scores and Visual Field Defect Size as Measured by 90° Standard Automated Perimetry in Patients with Postchiasmatic Lesions
NEI-VFQ Number of Absolute Defects in %
Eye with Larger VFL Eye with Smaller VFL
NEI-VFQ composite score of 11 subscales without general health (n = 148) −0.48, *** −0.40, ***
1. General health (n = 145) −0.08 (NS) −0.12 (NS)
2. General vision (n = 144) −0.28, ** −0.18*
3. Ocular pain (n = 143) −0.03 (NS) 0.07 (NS)
4. Near vision (n = 148) −0.28, ** −0.31, ***
5. Distance vision (n = 148) −0.40, *** −0.37, ***
6. Social functioning (n = 148) −0.43, *** −0.42, ***
7. Mental health (n = 143) −0.26, ** −0.28, **
8. Role difficulties (n = 138) −0.46, *** −0.44, ***
9. Dependency (n = 143) −0.42, *** −0.41, ***
10. Driving (n = 114) −0.33, *** −0.31, **
11. Color vision (n = 144) −0.39, *** −0.41, ***
12. Peripheral vision (n = 146) −0.47, *** −0.44, ***
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