Abstract
Purpose.:
To evaluate the associations between visual acuity and self-reported visual function; visual acuity and health-related quality of life (QoL) metrics; a summary measure of self-reported visual function and health-related QoL; and individual domains of self-reported visual function and health-related QoL in patients with uveitis.
Methods.:
Best-corrected visual acuity, vision-related functioning as assessed by the NEI VFQ-25, and health-related QoL as assessed by the SF-36 and EuroQoL EQ-5D questionnaires were obtained at enrollment in a clinical trial of uveitis treatments. Multivariate regression and Spearman correlations were used to evaluate associations between visual acuity, vision-related function, and health-related QoL.
Results.:
Among the 255 patients, median visual acuity in the better-seeing eyes was 20/25, the vision-related function score indicated impairment (median, 60), and health-related QoL scores were within the normal population range. Better visual acuity was predictive of higher visual function scores (P ≤ 0.001), a higher SF-36 physical component score, and a higher EQ-5D health utility score (P < 0.001). The vision-specific function score was predictive of all general health-related QoL (P < 0.001). The correlations between visual function score and general quality of life measures were moderate (ρ = 0.29–0.52).
Conclusions.:
The vision-related function score correlated positively with visual acuity and moderately positively with general QoL measures. Cost–utility analyses relying on changes in generic healthy utility measures will be more likely to detect changes when there are clinically meaningful changes in vision-related function, rather than when there are only changes in visual acuity. (ClinicalTrials.gov number, NCT00132691.)
Metrics evaluating quality of life (QoL) have gained importance with the introduction of cost-effectiveness analysis (CEA). CEA attempts to evaluate whether an improvement in health due to a new form of treatment is worth the cost of the treatment.
1 In practice, these analyses require data on general health-related QoL, specifically measures of health utility, to be generalizable across different treatments and diseases. In patients with uveitis specifically and eye disease in general, there is a paucity of research on the relationship of general health-related QoL and health utility metrics with visual acuity, an often used and clinically important outcome for evaluating the effectiveness of treatments for ocular diseases, or vision-related functioning. Vision-related functioning is a broader measure than visual acuity, because it evaluates patients' ability to conduct activities of daily living (e.g., reading, driving, and face recognition) for which peripheral vision, and contrast and color vision, as well as visual acuity, are important.
2 Previously, visual acuity and vision-related functioning have been shown to be strongly related in patients with other eye diseases,
3 and QoL scores are lower in uveitis patients than in healthy controls, especially among patients with significant vision loss.
4 However, the degree to which standard health utility measures change with clinically meaningful differences in visual acuity or vision-related functioning is uncertain for patients with uveitis and limited visual acuity impairment.
Studying the relationships in the path from visual acuity to visual function to generic health-related QoL (particularly health utility) for patients with uveitis specifically is worthwhile because uveitis differs from other conditions affecting visual acuity. Uveitis is a collection of approximately 30 diseases characterized by intraocular inflammation that are collectively an important cause of visual loss in the developed world.
5,6 Because noninfectious uveitis often strikes at a younger age than many common eye disorders, such as cataract, macular degeneration, and glaucoma, it has a disproportionately high impact on years of potential vision lost and workplace or home-based productivity effects.
7 In addition, pain is sometimes associated with uveitis that is not associated with other conditions, and visual acuity often fluctuates rather than being stable.
The Multicenter Uveitis Steroid Treatment (MUST) Trial was designed to evaluate the comparative effectiveness of a systemic treatment strategy, primarily oral corticosteroids that may be supplemented with immunosuppressive drugs, to the fluocinolone intraocular implant.
8 The primary outcome of the MUST Trial is the change in best corrected visual acuity after 2 years of follow-up. The study also collected data on several QoL metrics, including self-reported vision-related functioning assessed with the National Eye Institute Visual Function Questionnaire (NEI VFQ-25), health-related QoL assessed with the Medical Outcomes Study 36-Item Short Form (SF-36), and health utility assessed with the EuroQoL EQ-5D questionnaire. We present the associations between measures of vision (visual acuity and vision-related function) and the more general measures of QoL and heath utility that were obtained at enrollment in the MUST trial. Our objective, for patients with uveitis, was to test relationships between (1) visual acuity and specific elements of visual function; (2) visual acuity and summary measures of visual function and generic health related QoL; (3) visual function and the QoL measures, to allow for possible mediation; and (4) specific elements of visual function and health-related QoL, to further explore relationships from the third test.
Duke University, Durham, NC: Glenn J. Jaffe (Director), Michael Cusick, and Justis Ehlers. Former members: Claxton Baer, Sai Chavala, Pouya Dayani, Muge Kesen, Alex Melamud, Jawad A. Qureshi, Robert F. See, Cindy Skalak, Adrienne Williams Scott, and Robert K. Shuler.
Emory University, Atlanta, GA: Sunil Srivastava (Director) and Alicides Fernandes. Former members: Deborah Gibbs and Daniel F. Martin.
Johns Hopkins University, Baltimore, MD: James P. Dunn (Director), Ellen Arnold, Jeff Boring, Diane M. Brown, Alison G. Livingston, Kisten Nolan, and Terry Reed. Former members: Marie-Lynn Belair, Stephen G. Bolton, Joseph B. Brodine, Lisa M. Brune, Anat Galor, Adam Jacobowitz, Meera Kapoor, Sanjay Kedhar, Henry A. Leder, Yavette Morton, George B. Peters, Priscilla Soto Ricardo Stevenson, Michelle Tarver-Carr, Yue Wang, and Stephen Kim.
Massachusetts Eye Research and Surgery Institute, Cambridge, MA: C. Stephen Foster (Director), Angelica Contero, Linda Bruner, Kayleigh Fitzpatrick, David M. Hinkle, Jyothir Johnson, Danielle Marvell, and Jennifer Pinto. Former members: Sarah Acevedo, Fahd Anzaar, Tom Cesca, Karina Q. Lebron, Chandra Morgan Nita Patel, Janet Sprague, and Taygan Yilmaz.
National Eye Institute, Bethesda, MD: H. Nida Sen, (Director), Denise Cunningham, Darryl Hayes, Dessie Koutsandreas, Nupura Krishnadev, Theresa Larson, Annal D. Meleth, Richard Mercer, Robert B. Nussenblatt, Patti R. Sherry, Gregory L. Short, Wendy Smith, and Alana Temple. Former members: Allison Bamji, Hanna Coleman, Geetaniali Davuluri, Lisa Faia, Chloe Gottlieb, Guy V. Jirawuthiworavong, Julie C. Lew, Dominic Obiyor, Cheryl H. Perry, Natalia Potapova, Eric Weichel, Keith J. Wroblewski, and Steven Yeh.
New York Eye and Ear Infirmary, New York, NY: Paul A. Latkany (Director), Jason Badamo, Jenny Gallardo, Monica Lorenzo-Latkany, Robert Masini, Susan Morell, Ann Nour, Meredith Sanchez, and Kate Steinberg. Former members: Kenneth M. Boyd, Jacek Jarczynski, and Mirjana McGrosky.
Royal Victorian Eye & Ear Hospital, East Melbourne, Australia: Richard J. Stawell (Director), Lisa Breayley, Julie Ewing, Carly D'Sylva, Lauren Hodgson, Ignatios Koukouras, Lyndell Lim, Cecilia Ling, Rachel McIntosh, Andrew Newton, Richard Smallwood, and Ehud Zamir. Former members: Nicola Hunt, Lisa Jones, and Suzanne Williams.
Rush University Medical Center, Chicago, IL: Pauline T. Merrill (Director), Pam Hulvey, Elaine Kernbauer, Scott Toennessen, and Denise L. Voskuil-Marre. Former members: Bruce Gaines, Christina Giannoulis, Heena S. Khan, and Sarah J. Levine.
Texas Retina Associates, Dallas, TX: Robert C. Wang (Director), Hank Aguado, Sally Arceneaux, Kimberly Cummings, Gary E. Fish, Keith Gray, Nick Hesse, Susie Howden, Diana Jaramillo, Michael Mackens, Karin Mutz, and Brenda Sanchez. Former members: Jean Arnwine and David Callanan.
United Kingdom Institute of Ophthalmology, London, UK: Susan Lightman (Director), Timothy Stubbs, Simon Taylor, and Hamish Towler. Former member: Kate Edwards.
University of California at Los Angeles, Los Angeles, CA: Gary N. Holland (Director), Robert D. Almanzor, Jose Castellanos, Jean Pierre Hubschman, Ann K. Johiro, Michael A. Kapamajian, Ralph D. Levinson, and Susan S. Ransome. Former members: Christine R. Gonzales, Anurag Gupta, and Peter J. Kappel.
University of California at San Diego, San Diego, CA: William R. Freeman (Director), Denine E. Cochran, Igor Kozak, Vivian Nguyen, Stephen F. Oster, and Debbie Powell. Former members: Tom Clarkc, Joshua Hedaya, Tiara Kemper, Jacqueline M. LeMoine, Megan E. Loughran, Luzandra Magana, Francesca Mojana, and Victoria Morrison.
University of California at San Francisco, San Francisco, CA: Todd P. Margolis (Director), Nisha Acharya, David Clay, Claire M. Khouri, Mary Lew, Jay Stewart, and Ira G. Wong. Former member: Salena Lee.
University of Illinois at Chicago, Chicago, IL: Debra A. Goldstein (Director), Marcia Niec, Misel Ramirez, and Howard H. Tessler. Former members: Catherine E. Crooke and Dimitry Pyatetsky.
University of Miami, Miami, FL: Janet L. Davis (Director), Thomas Albini, Aura Pacini, and David A. Pinto. Former members: Daniela Castaño, Macy Ho, Jaclyn L. Kovach, Susan Pineda, Richard C.-S. Lin, Jackie K.-D. Nguyen, Kimberly E. Stepien, and Claudia Teran.
University of Michigan, Ann Arbor, MI: Susan G. Elner (Director), Rebecca Brown, Linda Fournier, Julie R. Gothrup, Richard Hackel, Moella Hesselgrave, Robert Prusak, and Stephen J. Saxe. Former members: Melissa Bergeron, Reneé Blosser, Carrie Chrisman-McClure, and Deanna Sizemore.
University of Pennsylvania, Philadelphia, PA: John H. Kempen (Director), Jim Berger, Joan DuPont, Sheri Grand, Dawn McCall, Albert M. Maguire, Laurel Weeny, Daniel Will, and Wei Xu. Former members: Tim Hopkins and Monique McRay.
University of South Florida, Tampa, FL: Peter Reed Pavan (Director), JoAnn Leto, Lori Mayor, Kim McDonald, Scott E. Pautler, Wyatt Saxon, and Judy Soto. Former members: Maria Ortiz and Dee Dee Szalay.
University of Southern California, Los Angeles, CA: Amani Fawzi, (Director), Lupe Cisneros, Elizabeth Corona, Jackie Douglass, Dean Eliott, Margaret Padilla, and Narsing A. Rao. Former members: Alexia Aguirre, Lawrence Chong, Rahul Khurana, Jennifer Lim, Rachel Mead, Sylvia Ramos, and Julie H. Tsai.
University of Utah, Salt Lake City, UT: Albert Vitale (Director), Paul S. Bernstein, Bonnie Carlstrom, James Gilman, Sandra Hanseen, Paula Morris, Diana Ramirez, and Kimberley Wegner.
Virginia Eye Consultants, Norfolk, VA: John D. Sheppard (Director), Brianne Anthony, Lisa Franklin, Krista Hamelin, Stephen V. Scoper, Jeanette Fernandez, Lisa Felix-Ken, and Rebecca Marx. Former members: Nancy Crawford, Rebecca De La Garza, R. Denise Cole, Jen Martin, Gregory Schultz, Joseph Webb, and Pamela Yeager.
Vitreoretinal Consultants, Houston, TX: Rosa Y. Kim (Director), Matthew S. Benz, David M. Brown, Eric Chen, Richard H. Fish, Shayla Hay, Jame Majo, Laura Shawver, and Tien P. Wong.
Washington University, St. Louis, MO: P. Kumar Rao (Director) and Rhonda Weeks. Former members: Rajendra S. Apte, Kevin J. Blinder, Pam Light, Gaurav K. Shah, and Russell VanGelder.
Executive Committee: Douglas A. Jabs (Chair), Michael M. Altaweel, Janet T. Holbrook, John H. Kempen, and Natalie Kurinij.
Steering Committee: Douglas A. Jabs (Chair), Robert D. Almanzor, Michael M. Altaweel, Diane Brown, James P. Dunn, James Gilman, Janet T. Holbrook, Gary N. Holland, John H. Kempen, Rosa Y. Kim, Natalie Kurinij, Nancy Prusakowski, and Jennifer E. Thorne. Former members: Stephen G. Bolton, Lisa M. Brune, Tom Clark, Larry Hubbard, Daniel F. Martin, and Robert B. Nussenblatt.
Data, Safety, and Monitoring Committee: Janet Wittes (Chair), William E. Barlow, Marc Hochberg, Janet T. Holbrook, Douglas A. Jabs, Natalie Kurinij, Alice T. Lyon, Michael M. Altaweel, Alan G. Palestine, Lee S. Simon, and Harmon Smith. Former member: James T. Rosenbaum.
Surgical Quality Assurance Committee: John H. Kempen (Chair), James P. Dunn, and Glenn J. Jaffe. Former member: Daniel F. Martin.
Medical Therapy Quality Assurance Committee: Jennifer E. Thorne (Chair), Nisha Acharya, Douglas A. Jabs, John H. Kempen, Paul A. Latkany, Robert B. Nussenblatt, and Albert Vitale. Former member: Russell VanGelder.
Visual Function Quality Assurance Committee: Robert D. Almanzor (Chair), Judith Alexander, Jeffrey A. Boring, Deborah Gibbs, Salena Lee, and Jennifer E. Thorne (Advisor). Former member: Wai Ping Ng.
Glaucoma Committee: David S. Friedman (Chair), Anna Adler, Alyce Burke, Janet T. Holbrook, Joanne Katz, John H. Kempen, Nancy Prusakowski, Susan Reed, and Jennifer E. Thorne. Former members: Nicholas Cohen, Sanjukta Modak, Wai Ping Ng.
Statistical Analysis Committee: Elizabeth A. Sugar (Chair), Lea Drye, Kevin Frick, Janet T. Holbrook, JoAnn Katz, Thomas Louis, Mark L. Van Natta. Former members: Sanjukta Modak and David Shade.
Chairman's Office: Mount Sinai School of Medicine, New York, NY: Douglas A. Jabs (Study Chairman), Yasmin Hilal, Melissa A. Nieves, Karen Pascual, and Jill S. Slutsky. Former members: Maria Stevens, and Colby Glomp.
University of Pennsylvania, Philadelphia, PA: John H. Kempen (Study Vice-Chairman).
Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD: Janet T. Holbrook, (Director), Anna Adler, Judith Alexander, Jeff Boring, Alyce Burke, Karen Collins, John Dodge, Lea Drye, Cathleen Ewing, Kevin Frick, David S. Friedman, Rosetta Jackson, Joanne Katz, Andrea Lears, Hope Livingston, Thomas Louis, Curtis Meinert, Jill Meinert, Vinnette Morrison, Deborah Nowakowski, Nancy Prusakowski, Dave Shade, Rochelle Smith, Karen Steuernagle, Elizabeth A. Sugar, Jennifer E. Thorne, James Tonascia, Mark L. Van Natta, and Richard Zheng. Former members: Paul Chen, Nicholas Cohen, Sanjukta Modak, Wai Ping Ng, Weijiang Shen, Charles Shiflett, and Ada Tieman.
Fundus Photograph Reading Center, University of Wisconsin, Madison, WI: Michael M. Altaweel, Wendy K. Benz, Geoffrey Chambers, Debra J. Christianson, Amitha Domalpally, Jacquelyn Freund, Vonnie Gama, Sapna Gangaputra, Kathleen E. Glander, Anne Goulding, Jeffrey M. Joyce, Christina N. Kruse, Dawn J. Myers, Susan Reed, James L. Reimers, Amy Remm, Ruth A. Susman, Dennis Thayer, Erika Treichel, Kelly J. Warren, Sheila M. Watson, James K. White, and Tara Wilhelmson. Former members: Margaret A. Fleischli, Dennis Hafford, Susan E. Harris, Larry D. Hubbard, Kristine A. Johnson, Lauren Nagle, Gwyn E. Padden-Lechten, Alyson Pohlman, Peggy Sivesind, Mary K. Webster, and Grace Zhang.
National Eye Institute, Bethesda, MD: Natalie Kurinij.