February 2010
Volume 51, Issue 2
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Clinical and Epidemiologic Research  |   February 2010
Vision-Related Quality of Life and Visual Function after Vitrectomy for Various Vitreoretinal Disorders
Author Affiliations & Notes
  • Fumiki Okamoto
    From the Department of Ophthalmology, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan.
  • Yoshifumi Okamoto
    From the Department of Ophthalmology, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan.
  • Shinichi Fukuda
    From the Department of Ophthalmology, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan.
  • Takahiro Hiraoka
    From the Department of Ophthalmology, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan.
  • Tetsuro Oshika
    From the Department of Ophthalmology, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan.
  • Corresponding author: Fumiki Okamoto, Department of Ophthalmology, Institute of Clinical Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575 Japan; fumiki-o@md.tsukuba.ac.jp
Investigative Ophthalmology & Visual Science February 2010, Vol.51, 744-751. doi:10.1167/iovs.09-3992
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      Fumiki Okamoto, Yoshifumi Okamoto, Shinichi Fukuda, Takahiro Hiraoka, Tetsuro Oshika; Vision-Related Quality of Life and Visual Function after Vitrectomy for Various Vitreoretinal Disorders. Invest. Ophthalmol. Vis. Sci. 2010;51(2):744-751. doi: 10.1167/iovs.09-3992.

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

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Abstract

Purpose.: To investigate vision-related quality of life (VR-QOL) in patients undergoing vitrectomy for various vitreoretinal disorders and to evaluate the relationship between VR-QOL and visual function.

Methods.: The study included 100 normal control subjects and 299 patients with various vitreoretinal disorders including proliferative diabetic retinopathy (PDR), diabetic macular edema (DME), branch retinal vein occlusion (BRVO), central retinal vein occlusion (CRVO), macular hole (MH), epiretinal membrane (ERM), and rhegmatogenous retinal detachment (RD). The 25-item National Eye Institute Visual Function Questionnaire (VFQ-25) was answered by the patients with vitreoretinal disorders before and 3 months after pars plana vitrectomy, as well as by the normal control subjects. Clinical data were collected, including visual acuity, contrast sensitivity, and severity of metamorphopsia.

Results.: Vitrectomy significantly improved the VFQ-25 composite score in all vitreoretinal disorders. Preoperative VFQ-25 composite scores in MH and ERM were significantly higher than those in PDR, DME, and BRVO. Postoperative VFQ-25 composite scores were significantly higher in MH, ERM, and RD than in PDR, DME, BRVO, and CRVO. A greater improvement in the VFQ-25 composite score was observed in ERM than in DME. Multiple regression analysis revealed that changes in contrast sensitivity had a significant correlation with changes in the VFQ-25 composite score in PDR and DME. Changes in metamorphopsia were significantly associated with changes in the VFQ-25 composite score in MH and ERM.

Conclusions.: Vitrectomy significantly improved VR-QOL in various vitreoretinal disorders. The largest improvement in VR-QOL was observed in ERM and smallest improvement in DME. The visual function parameters associated with VR-QOL are different depending on vitreoretinal disorders.

In ophthalmology, traditional objective clinical outcome measures such as visual acuity are increasingly being complemented with assessment of patients' perception of their visual function and quality of life. The National Eye Institute 25-Item Visual Function Questionnaire (VFQ-25) is a vision-related quality of life (VR-QOL) instrument designed to assess patients' perception of their visual function and QOL. 1 The VFQ-25 has been used to track the outcome of many ocular diseases. 216 Prior studies have reported the influence of vitrectomy on VR-QOL in patients with proliferative diabetic retinopathy (PDR), retinal detachment (RD), macular hole (MH), epiretinal membrane (ERM), and age-related macular degeneration (AMD). 1016 Such studies have demonstrated that vitrectomy can improve patients' visual function as well as VR-QOL. A comparison of changes in VR-QOL after surgery among the various vitreoretinal diseases, however, has not been conducted. In the present study, VR-QOL data from 100 normal subjects and 299 patients with various vitreoretinal disorders were assessed by the VFQ-25. The purpose of this study was to compare VR-QOL among vitreoretinal disorders and to evaluate the relationship between VR-QOL and visual function in each disorder. 
Methods
We included 99 patients with proliferative diabetic retinopathy (PDR), 38 patients with diabetic macular edema (DME), 20 patients with branch retinal vein occlusion (BRVO), 12 patients with central retinal vein occlusion (CRVO), 42 patients with macular hole (MH), 33 patients with epiretinal membrane (ERM), and 55 patients with rhegmatogenous retinal detachment (RD), all of whom were underwent pars plana vitrectomy at Tsukuba University Hospital between June 14, 2005, and April 20, 2007. One hundred volunteers served as normal control subjects. This research was conducted according to the tenets of the Declaration of Helsinki, and written informed consent was obtained from each suitable participant. This study was approved by the Institutional Review Board at the Tsukuba University Hospital. Exclusion criteria included patients with a history of vitreoretinal surgery and ocular disorders except for mild refractive errors and mild cataract. Patients who had undergone bilateral vitrectomy within 3 months were excluded. 
The logarithm of minimum angle of resolution best-corrected visual acuity (logMAR BCVA), letter contrast sensitivity (CS), and severity of metamorphopsia were obtained before surgery and at 3 months after surgery. 
CS was measured by the CSV-1000LV chart (Vector Vision, Columbus, OH). This instrument uses letter optotypes, all of which are the same size and of low spatial frequency (2.4 cyc/deg). 17 There were eight contrast levels (standard, 35.5%, 17.8%, 8.9%, 6.3%, 4.5%, 2.2%, and 1.1%), and each contrast level had three letters. The measurements were performed at a 2.5-m distance under full spectacle correction. The mean luminance was 81 cd/m2. The test results were recorded, not as the contrast threshold or CS, but as the number of 24 letters correctly identified. 18,19  
The severity of metamorphopsia was evaluated in the patients with MH and ERM (M-Charts; Inami Co., Tokyo, Japan). The M (metamorphopsia)-Charts consist of 19 dotted lines with dot intervals ranging from 0.2° to 2.0° of visual angle. If the straight line is replaced with a dotted line and the dot interval is changed from fine to coarse, the distortion of the line decreases with the increasing dot interval, until the dotted line appears straight. 20,21 At first, vertical straight lines (0°) were shown to the patient. If the patient recognized the line as straight, the metamorphopsia score was 0. If the patient recognized the line as irregular or curved, then subsequent pages of the M-Charts, in which the dot intervals of the dotted line change from fine to coarse, were shown one after another. When the patient recognized a dotted line as being straight, the visual angle that separated the dots was considered to represent his or her metamorphopsia score for a vertical line. The M-Charts were rotated 90° and the same test was performed with the horizontal lines. The examinations were repeated three times for each subject, to evaluate reproducibility of the results, and the mean was used for data analyses. The examination was performed at 30 cm and the refraction of the eye was corrected exactly for this distance. 
The indications for vitrectomy in the patients with PDR included recurrent or persistent nonclearing vitreous hemorrhage, traction or combined traction–rhegmatogenous retinal detachment, and adherent posterior hyaloid causing excessive macular traction. DME was defined by clinically significant macular edema according to the ETDRS guidelines, diagnosed by slit lamp biomicroscopy, and a central foveal thickness of ≥250 μm, as measured by optical coherence tomography (OCT, Stratus OCT 3000; Carl Zeiss Ophthalmic Systems-Humphrey Division, Dublin, CA), and vitrectomy was indicated when ≥3 months had passed after at least one session of laser treatment and when logMAR BCVA in the affected eye was 0.2 or worse. The indication for vitrectomy in BRVO and CRVO included persistent nonclearing vitreous hemorrhage and/or cystoid macular edema. The indication for vitrectomy in MH included stage II to IV full-thickness macular hole by means of slit lamp biomicroscopy with a 90-D fundus lens and OCT. ERM was defined as a translucent or semitranslucent membrane with macular thickening involving the center of the macula, with or without distortion and wrinkling of the inner retinal surface on biomicroscopy and OCT; vitrectomy was indicated if patients reported significant metamorphopsia. The indications for vitrectomy in RD included presence of causative horseshoe tears due to posterior vitreous detachment. 
Surgical Procedures
All surgeries were performed by a single surgeon (FO) under sub-Tenon local anesthesia. The crystalline lens was removed by phacoemulsification and intraocular lens implantation was performed when required, followed by 20-gauge, three-port pars plana vitrectomy or 25-gauge transconjunctival vitrectomy. With conventional contact lenses, posterior hyaloid separation and removal of the posterior vitreous membrane were performed. Peripheral retinal examination with scleral depression was performed to search for a retinal tear or dialysis in all cases. In the patients with PDR, bimanual delamination, en bloc dissection, and segmentation techniques were used to remove proliferative tissues, and when required, 20% sulfur hexafluoride (SF6) gas and/or silicone oil was injected. In the patients with ERM, the membrane was engaged and removed from the macula with a pick and intraocular forceps. In the patients with MH, the limiting membrane was peeled off with the aid of indocyanine green or triamcinolone acetonide, followed by injection 20% SF6 gas. In the patients with RD, surgical procedures comprised release of vitreous traction around the breaks, internal drainage of the subretinal fluid, total gas–fluid exchange (20% SF6), and endolaser photocoagulation. In the patients with macular edema due to DME, BRVO, and CRVO, triamcinolone acetonide (4 mg in 0.1 mL) was injected into the vitreous cavity, and 20 mg in 0.5 mL triamcinolone acetonide was administered into the sub-Tenon space of the superior temporal quadrant approximately 10 mm posterior to the limbus, at the end of surgery. 
Visual Function Questionnaire (VFQ-25)
The patients answered the VFQ-25 before surgery and 3 months after surgery. The preoperative VFQ-25 was completed 1 to 2 days before surgery. In the patients with RD, preoperative evaluation by VFQ-25 was not performed, because of the rapid nature of its onset. The research staff explained the questionnaire to the patients, gave instructions verbally, and provided assistance when required. The completed questionnaires were reviewed for missing data by the research staff. Before surgery, all the missing items were filled out by the subjects themselves. 
The VFQ-25 comprises 25 items that require the patient to assess the levels of difficulty of particular visual symptoms or day-to-day activities. 1 Each item is assigned to one of the following 12 subscales: general health, general vision, ocular pain, near activities, distance activities, social functioning, mental health, role difficulties, dependency, driving, color vision, and peripheral vision. The subscales are 0 to 100 points, where 100 indicates the highest possible function or minimal subjective impairment. The VFQ-25 composite score is calculated as the unweighted average response to all items, excluding the questions on general health. 1 The VFQ-25 used in this study was a Japanese version, with modifications to suit the Japanese culture and lifestyle. The modified NEI VFQ-25 questionnaire has been assessed for reliability and validity, and it has been shown to accurately measure VR-QOL in Japanese individuals. 22  
Statistical Analysis
The mean scores and standard deviations were calculated for each VFQ-25 subscale and the composite score, in the patients with vitreoretinal disorders and the normal control subjects. The Wilcoxon signed-ranks test was used to compare preoperative and postoperative results. The Mann-Whitney U test was performed to compare each subscale score and composite score between the patients with vitreoretinal disorders and the normal control subjects. Fisher's protected least-significant difference (PLSD) was performed to compare subscale scores, composite scores, and age among vitreoretinal disorders. The relationship between the preoperative and postoperative VFQ-25 composite scores and between the preoperative scores and changes in the VFQ-25 composite scores were examined with the Pearson's correlation coefficient. Before and after surgery, multiple regression analysis was performed to investigate the relationship between various explanatory variables and VFQ-25 composite scores. Variables tested were better-seeing BCVA, worse-seeing BCVA, better-seeing CS, worse-seeing CS, and severity of metamorphopsia. The relationship between changes in the VFQ-25 composite score and changes in the explanatory variables was also evaluated. All tests of association were considered statistically significant at P < 0.05 (StatView, ver. 5.0; SAS Inc., Cary, NC). 
Results
Table 1 summarizes the background data of the normal control subjects and the patients with vitreoretinal disorders. The patients in the RD group were significantly younger than those in the other groups (P < 0.05, Fisher's PLSD). Among the 299 patients with vitreoretinal disorders, 24 were pseudophakic and 275 were phakic; 180 patients underwent combined cataract surgery and vitrectomy. Fifty-two eyes had vitreous hemorrhage (42 eyes with PDR, 7 eyes with BRVO, 2 eyes with RD, and 1 eye with RD). 
Table 1.
 
Background Data of Normal Controls and Patients with Vitreoretinal Disorders
Table 1.
 
Background Data of Normal Controls and Patients with Vitreoretinal Disorders
NC PDR DME BRVO CRVO MH ERM RD
Eyes, n 100 99 38 20 12 42 33 55
Men/women 56/44 53/46 23/15 9/11 9/3 20/22 16/17 40/15
Age, y 61.2 ± 9.9 57.7 ± 12.9 62.7 ± 9.0 64.1 ± 9.1 62.4 ± 11.3 64.3 ± 9.6 67.0 ± 8.4 52.3 ± 13.2*
Vitrectomy significantly improved VFQ-25 composite score in all vitreoretinal disorders except for RD in which preoperative VFQ-25 was not tested (Fig. 1). Change in the VFQ-25 composite score was significantly higher in eyes with vitreous hemorrhage (15.0 ± 11.4) than in eyes without vitreous hemorrhage (7.8 ± 10.7). The results of pre- and postoperative VFQ-25 composite scores and 12 subscales in the patients with each vitreoretinal disorder and the normal control subjects are shown in Tables 2 and 3, respectively. The preoperative VFQ-25 composite score was significantly lower in the patients with vitreoretinal disorders than in the normal control subjects. In addition, the postoperative VFQ-25 composite scores remained significantly lower in the patients with disease than in the normal control subjects. 
Figure 1.
 
Preoperative and postoperative VFQ-25 composite scores in the patients with vitreoretinal disorders and in the normal control subjects. *P < 0.0001; †P < 0.01; ‡P < 0.05.
Figure 1.
 
Preoperative and postoperative VFQ-25 composite scores in the patients with vitreoretinal disorders and in the normal control subjects. *P < 0.0001; †P < 0.01; ‡P < 0.05.
Table 2.
 
Preoperative VFQ-25 Composite Score and 12 Subscales in the Patients with Vitreoretinal Disorders and the Normal Control Subjects
Table 2.
 
Preoperative VFQ-25 Composite Score and 12 Subscales in the Patients with Vitreoretinal Disorders and the Normal Control Subjects
VFQ-25 Scores NC PDR DME BRVO CRVO MH ERM
General health 57.8 (19.0) 39.1 (19.6)* 44.1 (19.7)† 40.0 (12.9)† 47.9 (17.4) 51.2 (17.4)‡ 55.3 (15.0)
General vision 71.6 (14.8) 44.2 (21.2)* 46.3 (18.1)* 44.0 (21.1)* 51.7 (21.7)† 56.2 (17.2) 53.9 (17.7)*
Ocular pain 80.6 (15.2) 75.1 (22.3) 73.4 (20.6) 73.1 (20.0) 78.1 (20.7) 82.1 (17.9) 76.1 (17.2)
Near activities 81.8 (14.1) 44.2 (22.6)* 46.5 (21.1)* 44.4 (14.8)* 54.9 (22.6)* 59.5 (19.6)* 57.1 (17.3)*
Distance activities 82.3 (13.5) 48.1 (22.8)* 51.5 (24.3)* 53.5 (18.5)* 56.3 (22.8)* 64.9 (21.3)* 60.7 (14.7)*
Social functioning 90.9 (11.1) 59.5 (24.2)* 55.6 (27.7)* 61.3 (19.4)* 66.7 (19.5)* 78.0 (19.3)* 71.6 (19.3)*
Mental health 87.0 (13.6) 43.6 (23.8)* 44.4 (25.8)* 50.9 (23.3)* 52.1 (29.0)* 69.3 (18.3)* 64.8 (16.6)*
Role difficulties 84.9 (15.9) 52.9 (26.0)* 53.3 (29.3)* 48.8 (25.9)* 58.3 (24.6)* 72.6 (23.0)† 67.0 (17.3)*
Dependency 95.5 (9.9) 53.3 (29.7)* 55.3 (31.7)* 62.5 (26.3)* 66.7 (23.3)* 83.1 (18.2)* 77.5 (17.7)*
Driving 83.5 (12.3) 41.7 (34.2)* 45.4 (34.5)* 42.7 (28.4)* 57.5 (23.7)* 75.0 (19.2) 61.5 (23.0)*
Color vision 94.0 (10.7) 69.5 (25.2)* 68.4 (23.7)* 70.0 (20.8)* 68.8 (24.1)* 86.6 (14.9)† 79.5 (14.6)*
Peripheral vision 82.5 (18.6) 46.6 (23.3)* 45.4 (26.5)* 46.3 (18.6)* 54.2 (20.9)* 67.9 (20.9)† 67.4 (17.1)*
Composite score 85.0 (9.1) 52.8 (19.0)* 53.0 (20.5)* 54.7 (15.5)* 60.4 (17.6)* 71.2 (14.3)* 66.9 (10.5)*
Table 3.
 
Postoperative VFQ-25 Composite Score and 12 Subscales in the Patients with Vitreoretinal Disorders and the Normal Control Subjects
Table 3.
 
Postoperative VFQ-25 Composite Score and 12 Subscales in the Patients with Vitreoretinal Disorders and the Normal Control Subjects
VFQ-25 Scores NC PDR DME BRVO CRVO MH ERM RD
General health 57.8 (19.0) 39.0 (20.6)* 46.7 (16.6)† 43.8 (16.0)† 41.7 (16.3)† 53.6 (17.1) 55.3 (15.0) 54.2 (16.6)
General vision 71.6 (14.8) 61.6 (17.6)* 53.2 (18.2)* 56.0 (19.0)† 60.0 (19.1)† 69.0 (14.1) 69.1 (11.3) 70.7 (14.9)
Ocular pain 80.6 (15.2) 79.0 (19.6) 75.7 (20.3) 73.6 (19.0) 83.3 (13.4) 84.8 (16.0) 87.9 (11.9)‡ 82.4 (14.7)
Near activities 81.8 (14.1) 55.6 (22.1)* 53.5 (21.0)* 63.3 (17.6)* 64.6 (19.2)† 70.2 (18.8)† 71.0 (18.2)† 75.3 (17.3)‡
Distance activities 82.3 (13.5) 58.8 (20.7)* 53.7 (23.6)* 63.8 (17.6)* 61.8 (17.2)† 72.2 (19.4)† 73.4 (16.0)† 75.6 (16.9)†
Social functioning 90.9 (11.1) 74.6 (72.7)* 62.2 (25.6)* 70.0 (18.3)* 67.7 (8.4)* 82.7 (15.6)† 83.0 (9.3)* 88.2 (14.9)
Mental health 87.0 (13.6) 59.1 (23.1)* 54.9 (26.2)* 57.5 (25.1)* 58.9 (25.2)* 76.6 (14.1)* 78.4 (13.1)† 77.5 (18.4)†
Role difficulties 84.9 (15.9) 62.6 (23.9)* 57.9 (29.3)* 60.6 (25.4)* 62.5 (27.2)† 78.6 (21.8) 76.5 (20.0)‡ 78.5 (24.3)
Dependency 95.5 (9.9) 66.3 (25.7)* 63.6 (31.8)* 73.2 (18.3)* 70.1 (22.9)* 85.7 (19.2)* 88.9 (11.0)* 87.2 (17.3)†
Driving 83.5 (12.3) 54.5 (33.0)* 47.1 (35.3)* 50.0 (29.2)* 65.0 (16.5)† 78.6 (12.6) 76.0 (16.9) 75.5 (24.0)
Color vision 94.0 (10.7) 72.2 (23.5)* 71.1 (27.0)* 76.3 (20.6)* 72.9 (16.7)* 85.7 (19.2)† 89.4 (12.5)‡ 94.0 (10.8)
Peripheral vision 82.5 (18.6) 58.4 (21.2)* 54.6 (23.1)* 60.0 (20.5)* 60.4 (22.5)† 75.8 (19.3) 72.7 (17.0)† 72.2 (21.0)†
Composite score 85.0 (9.1) 63.6 (17.5)* 59.0 (21.0)* 64.9 (15.0)* 66.4 (11.0)* 79.2 (13.0)‡ 78.5 (8.4)† 79.6 (14.2)‡
The box-and-whisker plots of the VFQ-25 scores in each group are displayed in Figure 2. The preoperative VFQ-25 composite scores in the patients with MH and ERM were significantly higher than those in the patients with PDR, DME, and BRVO. The postoperative VFQ-25 composite scores in the patients with the MH, ERM, and RD were significantly higher than those in the patients with PDR, DME, BRVO, and CRVO. Changes in the VFQ-25 composite scores in the patients with ERM were significantly larger than those in the patients with DME. 
Figure 2.
 
Box-and-whisker plots with the top and bottom boundaries of the boxes indicating the 75th and 25th percentiles, respectively. Whiskers above and below the box indicate the 90th and 10th percentiles, respectively. (A) Preoperative VFQ-25 composite score in the patients with vitreoretinal disorders. (B) Postoperative VFQ-25 composite score. (C) Changes in VFQ-25 composite score. *P < 0.0001; †P < 0.01; ‡P < 0.05.
Figure 2.
 
Box-and-whisker plots with the top and bottom boundaries of the boxes indicating the 75th and 25th percentiles, respectively. Whiskers above and below the box indicate the 90th and 10th percentiles, respectively. (A) Preoperative VFQ-25 composite score in the patients with vitreoretinal disorders. (B) Postoperative VFQ-25 composite score. (C) Changes in VFQ-25 composite score. *P < 0.0001; †P < 0.01; ‡P < 0.05.
When scores of all the patients with vitreoretinal disorders were analyzed, the preoperative VFQ-25 composite score correlated significantly with postoperative VFQ-25 composite score (r = 0.799, P < 0.0001, Fig. 3A) and changes in the VFQ-25 composite score (r = 0.549, P < 0.0001, Fig. 3B). The preoperative VFQ-25 composite score correlated significantly with the postoperative VFQ-25 composite score in each group (Table 4). In addition, the preoperative VFQ-25 composite score correlated significantly with changes in the VFQ-25 composite scores in the PDR, CRVO, MH, and ERM groups (Table 4). 
Figure 3.
 
(A) The preoperative VFQ-25 score versus postoperative VFQ-25 composite score in all the patients. (B) Preoperative VFQ-25 composite score versus changes in VFQ-25 composite score in all patients.
Figure 3.
 
(A) The preoperative VFQ-25 score versus postoperative VFQ-25 composite score in all the patients. (B) Preoperative VFQ-25 composite score versus changes in VFQ-25 composite score in all patients.
Table 4.
 
Relationship between Preoperative and Postoperative VFQ-25 Composite Scores and Changes in the Scores
Table 4.
 
Relationship between Preoperative and Postoperative VFQ-25 Composite Scores and Changes in the Scores
Preoperative and Postoperative VFQ-25 Composite Score Preoperative and Changes in VFQ-25 Composite Score
r P r P
PDR 0.757 <0.0001* −0.374 <0.0001*
DME 0.753 <0.0001* −0.251 0.130
BRVO 0.795 <0.0001* −0.364 0.116
CRVO 0.687 <0.05* −0.783 <0.005*
MH 0.833 <0.0001* −0.418 <0.01*
ERM 0.611 <0.0001* −0.624 <0.0001*
Table 5 shows pre- and postoperative visual function in the patients with each disorder. Vitrectomy significantly improved BCVA and CS in all the disease groups except CRVO. The surgery significantly improved metamorphopsia in MH and ERM. 
Table 5.
 
Preoperative and Postoperative Visual Function in the Patients with Vitreoretinal Disorders
Table 5.
 
Preoperative and Postoperative Visual Function in the Patients with Vitreoretinal Disorders
BCVA CS Metamorphopsia
Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative
PDR 1.37 ± 0.75 0.53 ± 0.62* 5.4 ± 7.2 14.0 ± 7.9*
DME 0.76 ± 0.49 0.55 ± 0.51† 9.2 ± 6.5 12.7 ± 7.1*
BRVO 1.25 ± 0.63 0.38 ± 0.38† 6.5 ± 6.9 15.5 ± 6.9†
CRVO 1.23 ± 0.59 1.14 ± 0.47 2.7 ± 6.1 3.9 ± 6.5
MH 0.76 ± 0.38 0.49 ± 0.33* 14.3 ± 7.1 18.5 ± 4.3† 0.92 ± 0.52 0.42 ± 0.37*
ERM 0.47 ± 0.29 0.22 ± 0.28* 15.0 ± 5.2 19.0 ± 5.2* 0.83 ± 0.48 0.34 ± 0.42*
RD 0.55 ± 0.65 0.15 ± 0.24* 17.4 ± 3.4 19.7 ± 3.9†
Tables 6, 7, and 8 summarize the results of multiple regression analysis on the relation between the VFQ-25 composite score and several explanatory variables, including visual function parameters. The preoperative better-seeing BCVA exhibited significant correlation with the preoperative VFQ-25 composite score in the patients with PDR and DME. In ERM, the preoperative severity of metamorphopsia showed significant correlation with the VFQ-25 composite score (Table 6). After surgery, the better- and worse-seeing BCVAs exhibited significant correlation with the postoperative VFQ-25 composite score in the patients with PDR. The postoperative severity of metamorphopsia showed significant correlation with the VFQ-25 composite score in MH and ERM. In the patients with RD, the postoperative VFQ-25 composite score correlated significantly with the postoperative worse-seeing CS (Table 7). In MH and ERM, changes in the severity of metamorphopsia were significantly relevant to changes in the VFQ-25 composite score, but changes in other variables were not, including BCVA and CS. In addition, changes in the VFQ-25 composite score exhibited significant correlation with CS, not with BCVA in the patients with PDR and DME (Table 8). 
Table 6.
 
Results of Multiple Regression Analyses of Preoperative Composite Score and Explanatory Variables
Table 6.
 
Results of Multiple Regression Analyses of Preoperative Composite Score and Explanatory Variables
BCVA CS Metamorphopsia
Better-Seeing Worse-Seeing Better-Seeing Worse-Seeing
PDR 0.012* 0.215 0.969 0.672
DME 0.004* 0.594 0.187 0.943
BRVO 0.552 0.490 0.234 0.535
CRVO 0.244 0.729 0.664 0.702
MH 0.308 0.598 0.061 0.430 0.106
ERM 0.362 0.340 0.165 0.705 0.049*
Table 7.
 
Results of Multiple Regression Analysis on Postoperative VFQ-25 Composite Score and Explanatory Variables
Table 7.
 
Results of Multiple Regression Analysis on Postoperative VFQ-25 Composite Score and Explanatory Variables
BCVA CS Metamorphopsia
Better-Seeing Worse-Seeing Better-Seeing Worse-Seeing
PDR 0.033* 0.005* 0.824 0.311
DME 0.008* 0.337 0.067 0.871
BRVO 0.802 0.284 0.998 0.960
CRVO 0.752 0.992 0.742 0.917
MH 0.066 0.007* 0.903 0.437 0.005*
ERM 0.128 0.097 0.412 0.250 0.048*
RD 0.181 0.891 0.968 0.047*
Table 8.
 
Results of Multiple Regression Analysis on Changes in VFQ-25 Composite Score and Explanatory Variables
Table 8.
 
Results of Multiple Regression Analysis on Changes in VFQ-25 Composite Score and Explanatory Variables
Changes in
BCVA CS Metamorphopsia
PDR 0.273 0.003*
DME 0.176 <0.0001*
BRVO 0.716 0.056
CRVO 0.609 0.288
MH 0.260 0.145 0.013*
ERM 0.993 0.328 0.009*
Discussion
In our present study, pre- and postoperative VR-QOL was assessed using VFQ-25 in the patients with various vitreoretinal disorders. The level of pre- and postoperative VR-QOL as well as changes in VR-QOL showed a wide variation depending on the type of disease. The VFQ-25 used in this study was a Japanese version, with modifications to suit the Japanese. One item was changed to make it more appropriate to the Japanese lifestyle and culture. The modified NEI VFQ-25 questionnaire has been assessed for reliability and validity, and it has been shown to accurately measure VR-QOL in Japanese individuals. 22 The VFQ-25 composite scores in our results were similar to those in the study using the original NEI VFQ-25 in patients with MH, ERM, DME, and CRVO. 9,13,15,23 When the preoperative VFQ-25 composite scores were compared among vitreoretinal diseases, we found that they were relatively high in MH and ERM, whereas those in PDR, DME, and CRVO tended to be lower. In addition, postoperative VR-QOL was relatively high in MH, ERM, and RD, but low in PDR, DME, BRVO, and CRVO. Such polarization can be attributed to the characteristics of individual vitreoretinal disorders. PDR and DME usually affect both eyes, and visual performance in these patients is often inferior to that in patients with other vitreoretinal diseases. VR-QOL in PDR and DME was found to be poorer because VR-QOL was also significantly influenced by the visual performance of the fellow eyes. Hariprasad et al. 23 demonstrated that the VFQ-25 composite score of patients with DME was similar to that of individuals with age-related macular degeneration, but lower than that of patients with type 1 diabetic retinopathy, glaucoma, and cataracts. On the other hand, MH, ERM, and RD are generally unilateral, and the visual performance of patients' fellow eyes remained unaffected. For this reason, preoperative VR-QOL in the patients with these unilateral diseases was rather high. As for patients with BRVO and CRVO who undergo vitrectomy, visual function, including visual acuity and visual field, is significantly decreased in many cases and thus it is not surprising that VR-QOL in these patients is also decreased compared with patients with MH and ERM. 
As shown in the results, VR-QOL on each vitreoretinal disorder was significantly improved by vitrectomy. Previous studies have reported improvement in VR-QOL after ophthalmic surgery, such as cataract surgery, photorefractive excimer laser keratectomy, laser in situ keratomileusis and vitrectomy for PDR, ERM, MH, and age-related macular degeneration. 10,12,13,15,16,2427 In this study, we compared the changes in the VFQ-25 composite scores among vitreoretinal disorders and found a statistically significant difference between ERM and DME. The preoperative VFQ-25 composite score in ERM was significantly lower than that in MH, but increased to a level similar to that of MH after surgery. Gupta et al. 28 used quality-adjusted-life-years (QALYs) methods to investigate VR-QOL in patients with ERM and reported that vitrectomy for ERM was a highly cost-effective procedure. The cost-effectiveness ratio of ERM surgery was higher than that of MH surgery. In MH, the preoperative VFQ-25 composite score was relatively high, and thus surgery-induced improvement in VR-QOL remained rather small. In PDR, the VFQ-25 composite score gained considerable increases by surgery, 10.8 points, but a wide variation was observed among patients. In DME and CRVO, we found that changes in the VFQ-25 composite score due to vitrectomy were 5 points or less. Thus, effectiveness of vitrectomy in these diseases may be relatively low. 
Postoperative VR-QOL, even after successful vitrectomy in each vitreoretinal disorder, did not reach the level of that in the normal control subjects. This finding is consistent with the results of previous case–control studies on VR-QOL in retinal disorders such as rhegmatogenous retinal detachment and proliferative diabetic retinopathy. 10,11 These results indicate the importance and need for further improvement in surgical techniques and procedures, reviewing the timing of treatment, establishing means of early recognition and treatment, and considering effective prophylactic measures. When the scores were analyzed in the patients with vitreoretinal disorders altogether, preoperative VR-QOL was significantly associated with postoperative VR-QOL as well as changes in VR-QOL. It is suggested that surgical treatment should be considered as early as possible after a vitreoretinal disorder is recognized, so that vitrectomy can be performed to prevent further deterioration of the patient's VR-QOL. 
Multiple regression analysis revealed that the preoperative better-seeing BCVA correlated significantly with the preoperative VFQ-25 composite score in the patients with PDR and DME, in agreement with previous reports. 10,29 Miskala et al. 29 investigated VR-QOL in patients with subfoveal choroidal neovascularization using VFQ-25, and demonstrated that changes in the overall and subscale scores were linearly related to changes in visual acuity of the better-seeing eye but are not associated with changes in the worse-seeing eye. In ERM, preoperative severity of metamorphopsia showed significant correlation with VFQ-25 composite score, whereas preoperative visual acuity and CS showed no relationship with VFQ-25 composite score. This observation is not consistent with the result of a previous study by Ghazi-Nouri et al., 15 in which VFQ-25 responses significantly correlated with visual acuity, but not with CS and metamorphopsia in patients with ERM. Such discrepancy between our and prior studies may be attributable to the different methodology used to evaluate metamorphopsia. In previous studies, the severity of metamorphopsia was estimated using the Amsler charts, whereas we used the M-Charts to quantitatively record the severity of metamorphopsia in this study. With the Amsler chart, precise and reproducible assessment of metamorphopsia is difficult because patients have to self-describe the extent and degree of image distortion. On the other hand, the M-Charts can evaluate the degree of metamorphopsia quantitatively, since patients need simply to indicate whether the dotted line is distorted. 
Multiple regression analysis revealed that the postoperative better- and worse-seeing BCVAs correlated significantly with the preoperative VFQ-25 composite score in the patients with PDR. These results are consistent with those in a previous report that assessed the relationship between postoperative BCVA and VFQ-25 score in the patients with PDR by simple regression analysis. 10 In PDR, the mean visual acuity in the better-seeing eye deteriorated considerably, and the difference between the better- and worse-seeing eyes was small. This slight difference seems to be the reason that VFQ-25 score correlated with the visual function not only in the better-seeing eye but also in the worse-seeing eye. 
By multiple regression analysis, we found that change in the severity of metamorphopsia was the single factor relevant to VR-QOL in the patients with MH and ERM, while visual acuity and CS were not relevant factors. Until now, there has been no report that showed a significant relationship between increases in VR-QOL and improvement in visual function in patients with MH and ERM. Our results indicated that metamorphopsia plays a key role in the deterioration of visual functioning and VR-QOL in patients with MH and ERM. 
As the results showed, changes in the VFQ-25 composite score exhibited significant correlation with CS, not with BCVA in the patients with PDR and DME. In several investigations of QOL outcomes after ocular surgery, only a weak or no correlation was observed between increases in QOL and improvement in visual acuity. 12,30 Visual acuity can be a poor predictor of many aspects of visual function. 31,32 CS has been shown to correlate with various aspects of activities requiring vision, including orientation, mobility, reading speed, and driving. 33,34 Carta et al. 35 reported that CS was strongly associated with VR-QOL, even with adjustment for visual acuity among ophthalmic patients with chronic eye conditions such as age-related macular degeneration. In the patients who underwent retinal detachment surgery, the postoperative VFQ-25 composite score correlated significantly with CS and low-contrast visual acuity, whereas there was no correlation between the VFQ-25 composite score and BCVA. 11 In other studies, VFQ-25 responses correlated with CS as well as visual acuity in patients with diabetes mellitus and age-related macular degeneration. 2,36 It is noteworthy that improvement in CS was significantly associated with increases in VR-QOL in the patients with PDR and DME in our study. 
Our study had several limitations. First, the sample size was rather small, especially the number of patients with BRVO and CRVO, and that may have influenced the VFQ-25 measurements. Second, postoperative follow-up was short. We evaluated the patients at 3 months after surgery. It has been reported that the VFQ-25 score in the patients with ERM improved more at 1 year than at 3 months after surgery. 15 Thus, long-term investigations of patients after vitrectomy may yield different results regarding VR-QOL. Third, there may be some placebo effect in VFQ-25 measurements. The patients obviously recognized that they had surgery and may have answered postoperative VFQ-25 questions more positively with an expectation that they would benefit from the surgery. This effect cannot be avoided in designing the study, but it could account for some of the improvements in the VFQ-25 scores. Future studies with a larger sample size and longer follow-up period, with some attempt to avoid the placebo effect, will further facilitate our understanding of VR-QOL in patients undergoing surgery for vitreoretinal disorders. 
Footnotes
 Disclosure: F. Okamoto, None; Y. Okamoto, None; S. Fukuda, None; T. Hiraoka, None; T. Oshika, None
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Figure 1.
 
Preoperative and postoperative VFQ-25 composite scores in the patients with vitreoretinal disorders and in the normal control subjects. *P < 0.0001; †P < 0.01; ‡P < 0.05.
Figure 1.
 
Preoperative and postoperative VFQ-25 composite scores in the patients with vitreoretinal disorders and in the normal control subjects. *P < 0.0001; †P < 0.01; ‡P < 0.05.
Figure 2.
 
Box-and-whisker plots with the top and bottom boundaries of the boxes indicating the 75th and 25th percentiles, respectively. Whiskers above and below the box indicate the 90th and 10th percentiles, respectively. (A) Preoperative VFQ-25 composite score in the patients with vitreoretinal disorders. (B) Postoperative VFQ-25 composite score. (C) Changes in VFQ-25 composite score. *P < 0.0001; †P < 0.01; ‡P < 0.05.
Figure 2.
 
Box-and-whisker plots with the top and bottom boundaries of the boxes indicating the 75th and 25th percentiles, respectively. Whiskers above and below the box indicate the 90th and 10th percentiles, respectively. (A) Preoperative VFQ-25 composite score in the patients with vitreoretinal disorders. (B) Postoperative VFQ-25 composite score. (C) Changes in VFQ-25 composite score. *P < 0.0001; †P < 0.01; ‡P < 0.05.
Figure 3.
 
(A) The preoperative VFQ-25 score versus postoperative VFQ-25 composite score in all the patients. (B) Preoperative VFQ-25 composite score versus changes in VFQ-25 composite score in all patients.
Figure 3.
 
(A) The preoperative VFQ-25 score versus postoperative VFQ-25 composite score in all the patients. (B) Preoperative VFQ-25 composite score versus changes in VFQ-25 composite score in all patients.
Table 1.
 
Background Data of Normal Controls and Patients with Vitreoretinal Disorders
Table 1.
 
Background Data of Normal Controls and Patients with Vitreoretinal Disorders
NC PDR DME BRVO CRVO MH ERM RD
Eyes, n 100 99 38 20 12 42 33 55
Men/women 56/44 53/46 23/15 9/11 9/3 20/22 16/17 40/15
Age, y 61.2 ± 9.9 57.7 ± 12.9 62.7 ± 9.0 64.1 ± 9.1 62.4 ± 11.3 64.3 ± 9.6 67.0 ± 8.4 52.3 ± 13.2*
Table 2.
 
Preoperative VFQ-25 Composite Score and 12 Subscales in the Patients with Vitreoretinal Disorders and the Normal Control Subjects
Table 2.
 
Preoperative VFQ-25 Composite Score and 12 Subscales in the Patients with Vitreoretinal Disorders and the Normal Control Subjects
VFQ-25 Scores NC PDR DME BRVO CRVO MH ERM
General health 57.8 (19.0) 39.1 (19.6)* 44.1 (19.7)† 40.0 (12.9)† 47.9 (17.4) 51.2 (17.4)‡ 55.3 (15.0)
General vision 71.6 (14.8) 44.2 (21.2)* 46.3 (18.1)* 44.0 (21.1)* 51.7 (21.7)† 56.2 (17.2) 53.9 (17.7)*
Ocular pain 80.6 (15.2) 75.1 (22.3) 73.4 (20.6) 73.1 (20.0) 78.1 (20.7) 82.1 (17.9) 76.1 (17.2)
Near activities 81.8 (14.1) 44.2 (22.6)* 46.5 (21.1)* 44.4 (14.8)* 54.9 (22.6)* 59.5 (19.6)* 57.1 (17.3)*
Distance activities 82.3 (13.5) 48.1 (22.8)* 51.5 (24.3)* 53.5 (18.5)* 56.3 (22.8)* 64.9 (21.3)* 60.7 (14.7)*
Social functioning 90.9 (11.1) 59.5 (24.2)* 55.6 (27.7)* 61.3 (19.4)* 66.7 (19.5)* 78.0 (19.3)* 71.6 (19.3)*
Mental health 87.0 (13.6) 43.6 (23.8)* 44.4 (25.8)* 50.9 (23.3)* 52.1 (29.0)* 69.3 (18.3)* 64.8 (16.6)*
Role difficulties 84.9 (15.9) 52.9 (26.0)* 53.3 (29.3)* 48.8 (25.9)* 58.3 (24.6)* 72.6 (23.0)† 67.0 (17.3)*
Dependency 95.5 (9.9) 53.3 (29.7)* 55.3 (31.7)* 62.5 (26.3)* 66.7 (23.3)* 83.1 (18.2)* 77.5 (17.7)*
Driving 83.5 (12.3) 41.7 (34.2)* 45.4 (34.5)* 42.7 (28.4)* 57.5 (23.7)* 75.0 (19.2) 61.5 (23.0)*
Color vision 94.0 (10.7) 69.5 (25.2)* 68.4 (23.7)* 70.0 (20.8)* 68.8 (24.1)* 86.6 (14.9)† 79.5 (14.6)*
Peripheral vision 82.5 (18.6) 46.6 (23.3)* 45.4 (26.5)* 46.3 (18.6)* 54.2 (20.9)* 67.9 (20.9)† 67.4 (17.1)*
Composite score 85.0 (9.1) 52.8 (19.0)* 53.0 (20.5)* 54.7 (15.5)* 60.4 (17.6)* 71.2 (14.3)* 66.9 (10.5)*
Table 3.
 
Postoperative VFQ-25 Composite Score and 12 Subscales in the Patients with Vitreoretinal Disorders and the Normal Control Subjects
Table 3.
 
Postoperative VFQ-25 Composite Score and 12 Subscales in the Patients with Vitreoretinal Disorders and the Normal Control Subjects
VFQ-25 Scores NC PDR DME BRVO CRVO MH ERM RD
General health 57.8 (19.0) 39.0 (20.6)* 46.7 (16.6)† 43.8 (16.0)† 41.7 (16.3)† 53.6 (17.1) 55.3 (15.0) 54.2 (16.6)
General vision 71.6 (14.8) 61.6 (17.6)* 53.2 (18.2)* 56.0 (19.0)† 60.0 (19.1)† 69.0 (14.1) 69.1 (11.3) 70.7 (14.9)
Ocular pain 80.6 (15.2) 79.0 (19.6) 75.7 (20.3) 73.6 (19.0) 83.3 (13.4) 84.8 (16.0) 87.9 (11.9)‡ 82.4 (14.7)
Near activities 81.8 (14.1) 55.6 (22.1)* 53.5 (21.0)* 63.3 (17.6)* 64.6 (19.2)† 70.2 (18.8)† 71.0 (18.2)† 75.3 (17.3)‡
Distance activities 82.3 (13.5) 58.8 (20.7)* 53.7 (23.6)* 63.8 (17.6)* 61.8 (17.2)† 72.2 (19.4)† 73.4 (16.0)† 75.6 (16.9)†
Social functioning 90.9 (11.1) 74.6 (72.7)* 62.2 (25.6)* 70.0 (18.3)* 67.7 (8.4)* 82.7 (15.6)† 83.0 (9.3)* 88.2 (14.9)
Mental health 87.0 (13.6) 59.1 (23.1)* 54.9 (26.2)* 57.5 (25.1)* 58.9 (25.2)* 76.6 (14.1)* 78.4 (13.1)† 77.5 (18.4)†
Role difficulties 84.9 (15.9) 62.6 (23.9)* 57.9 (29.3)* 60.6 (25.4)* 62.5 (27.2)† 78.6 (21.8) 76.5 (20.0)‡ 78.5 (24.3)
Dependency 95.5 (9.9) 66.3 (25.7)* 63.6 (31.8)* 73.2 (18.3)* 70.1 (22.9)* 85.7 (19.2)* 88.9 (11.0)* 87.2 (17.3)†
Driving 83.5 (12.3) 54.5 (33.0)* 47.1 (35.3)* 50.0 (29.2)* 65.0 (16.5)† 78.6 (12.6) 76.0 (16.9) 75.5 (24.0)
Color vision 94.0 (10.7) 72.2 (23.5)* 71.1 (27.0)* 76.3 (20.6)* 72.9 (16.7)* 85.7 (19.2)† 89.4 (12.5)‡ 94.0 (10.8)
Peripheral vision 82.5 (18.6) 58.4 (21.2)* 54.6 (23.1)* 60.0 (20.5)* 60.4 (22.5)† 75.8 (19.3) 72.7 (17.0)† 72.2 (21.0)†
Composite score 85.0 (9.1) 63.6 (17.5)* 59.0 (21.0)* 64.9 (15.0)* 66.4 (11.0)* 79.2 (13.0)‡ 78.5 (8.4)† 79.6 (14.2)‡
Table 4.
 
Relationship between Preoperative and Postoperative VFQ-25 Composite Scores and Changes in the Scores
Table 4.
 
Relationship between Preoperative and Postoperative VFQ-25 Composite Scores and Changes in the Scores
Preoperative and Postoperative VFQ-25 Composite Score Preoperative and Changes in VFQ-25 Composite Score
r P r P
PDR 0.757 <0.0001* −0.374 <0.0001*
DME 0.753 <0.0001* −0.251 0.130
BRVO 0.795 <0.0001* −0.364 0.116
CRVO 0.687 <0.05* −0.783 <0.005*
MH 0.833 <0.0001* −0.418 <0.01*
ERM 0.611 <0.0001* −0.624 <0.0001*
Table 5.
 
Preoperative and Postoperative Visual Function in the Patients with Vitreoretinal Disorders
Table 5.
 
Preoperative and Postoperative Visual Function in the Patients with Vitreoretinal Disorders
BCVA CS Metamorphopsia
Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative
PDR 1.37 ± 0.75 0.53 ± 0.62* 5.4 ± 7.2 14.0 ± 7.9*
DME 0.76 ± 0.49 0.55 ± 0.51† 9.2 ± 6.5 12.7 ± 7.1*
BRVO 1.25 ± 0.63 0.38 ± 0.38† 6.5 ± 6.9 15.5 ± 6.9†
CRVO 1.23 ± 0.59 1.14 ± 0.47 2.7 ± 6.1 3.9 ± 6.5
MH 0.76 ± 0.38 0.49 ± 0.33* 14.3 ± 7.1 18.5 ± 4.3† 0.92 ± 0.52 0.42 ± 0.37*
ERM 0.47 ± 0.29 0.22 ± 0.28* 15.0 ± 5.2 19.0 ± 5.2* 0.83 ± 0.48 0.34 ± 0.42*
RD 0.55 ± 0.65 0.15 ± 0.24* 17.4 ± 3.4 19.7 ± 3.9†
Table 6.
 
Results of Multiple Regression Analyses of Preoperative Composite Score and Explanatory Variables
Table 6.
 
Results of Multiple Regression Analyses of Preoperative Composite Score and Explanatory Variables
BCVA CS Metamorphopsia
Better-Seeing Worse-Seeing Better-Seeing Worse-Seeing
PDR 0.012* 0.215 0.969 0.672
DME 0.004* 0.594 0.187 0.943
BRVO 0.552 0.490 0.234 0.535
CRVO 0.244 0.729 0.664 0.702
MH 0.308 0.598 0.061 0.430 0.106
ERM 0.362 0.340 0.165 0.705 0.049*
Table 7.
 
Results of Multiple Regression Analysis on Postoperative VFQ-25 Composite Score and Explanatory Variables
Table 7.
 
Results of Multiple Regression Analysis on Postoperative VFQ-25 Composite Score and Explanatory Variables
BCVA CS Metamorphopsia
Better-Seeing Worse-Seeing Better-Seeing Worse-Seeing
PDR 0.033* 0.005* 0.824 0.311
DME 0.008* 0.337 0.067 0.871
BRVO 0.802 0.284 0.998 0.960
CRVO 0.752 0.992 0.742 0.917
MH 0.066 0.007* 0.903 0.437 0.005*
ERM 0.128 0.097 0.412 0.250 0.048*
RD 0.181 0.891 0.968 0.047*
Table 8.
 
Results of Multiple Regression Analysis on Changes in VFQ-25 Composite Score and Explanatory Variables
Table 8.
 
Results of Multiple Regression Analysis on Changes in VFQ-25 Composite Score and Explanatory Variables
Changes in
BCVA CS Metamorphopsia
PDR 0.273 0.003*
DME 0.176 <0.0001*
BRVO 0.716 0.056
CRVO 0.609 0.288
MH 0.260 0.145 0.013*
ERM 0.993 0.328 0.009*
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