The Impact of Visual Impairment and Eye Disease on

Vision-Related Quality of Life in a Mexican-American

Population: Proyecto VER
Aimee Teo Broman,1 Beatriz Munoz,1 Jorge Rodriguez,2,3 Rosario Sanchez,2
Harry A. Quigley,1 Ronald Klein,4 Robert Snyder,2 and Sheila K. West1
PURPOSE. To describe the relationship of visual acuity impairment and eye disease on vision-related quality of life, as measured by the 25-item National Eye Institute Visual Function
Questionnaire (NEI-VFQ-25), in a cross-sectional, populationbased study of older Hispanic persons living in Arizona.
METHODS. A random sample of block groups with Hispanic
residents in Nogales and Tucson, Arizona, were selected for
study. Participants were interviewed at home with a questionnaire that included the NEI-VFQ-25, an instrument measuring
vision-related quality of life. Acuity was obtained with Early
Treatment Diabetic Retinopathy Study (ETDRS) charts and
standard protocol. Cataract was determined by clinical examination, diabetic retinopathy was diagnosed on stereo fundus
photographs, and glaucoma was diagnosed on the basis of
clinical examination and visual field results. Analyses were
done to determine the degree of association between subscale
scores and acuity in the better-seeing eye, monocular visual
impairment, and specific eye diseases, with adjustment for
acuity.
RESULTS. Of the 4774 participants in the study, 99.7% had
completed questionnaires that were not completed by proxy.
Participants with visual impairment had associated decrements
in scores on all subscales, with a decrease in presenting acuity
associated with a worse score (P 0.05), after adjustment for
demographic variables. Monocular impairment was also associated with lower scores in several subscales. In those with
cataract, low acuity explained most of the low scores, but
those with glaucoma or diabetic retinopathy had low scores
independent of acuity.
CONCLUSIONS. In this study of Mexican-American persons aged
40 or more, monocular impairment and better-eye acuity was
associated with a decrease in most domains representing quality of life. Subjects with uncorrected refractive error, cataract,
diabetic retinopathy, and glaucoma had associated decrements
in quality of life, many not explained by loss of acuity. Further
work on the specific measures of vision associated with reported decreases in quality of life, such as visual field or
From the 1Dana Center for Preventive Ophthalmology, Johns
Hopkins School of Medicine, Baltimore, Maryland; the 2Department of
Ophthalmology, University of Arizona, Tuscon, Arizona; and the 4Department of Ophthalmology, University of Wisconsin, Madison, Wisconsin.
3
Deceased, September 2002.
Supported by Grant U10-EY11283 from the National Eye Institute.
SKW is a Research to Prevent Blindness Senior Scientific Investigator.
Submitted for publication August 13, 2001; revised May 1, 2002;
accepted May 30, 2002.
Commercial relationships policy: N.
The publication costs of this article were defrayed in part by page
charge payment. This article must therefore be marked advertisement in accordance with 18 U.S.C. 1734 solely to indicate this fact.
Corresponding author: Sheila K. West, Wilmer Eye Institute, Room
129, Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD
21287; shwest@jhmi.edu.
Investigative Ophthalmology & Visual Science, November 2002, Vol. 43, No. 11
Copyright Association for Research in Vision and Ophthalmology

contrast sensitivity, is warranted. (Invest Ophthalmol Vis Sci.

2002;43:33933398)

he Hispanic population is the fastest growing minority

group in the United States, and there is considerable interest in the health status of this heterogeneous population.1 In
particular, the eye health of this population is of concern,
because there is a relatively high rate of visual impairment2
compared with that in non-Hispanic whites. In previous publications, we have reported high rates of diabetic retinopathy
(DR) in a Mexican-American population, attributable to the
high prevalence of diabetes in this group.3 Rates of glaucoma
also appear to be higher than in the non-Hispanic white population.4
However, not much is known about the impact of visual
impairment on the quality of life in this population. Impairment in acuity has been associated with self-reported difficulties in physical function,57 emotional distress,8 and low socialization8,9all domains that are considered part of quality of
life. As part of the validation of the National Eye Institute Visual
Function Questionnaire (NEI-VFQ), decreases in scores associated with vision loss due to glaucoma, DR, and cataract have
been reported.10 12 However, the independent contributions
of disease beyond acuity impairment have not been well characterized.
In a previous report, we described the psychometric properties of the short version, the NEI-VFQ-25, in this MexicanAmerican population, showing the association of visual acuity
impairment and demographic variables with scores in qualityof-life domains.13 In that report, we demonstrated the validity
of the NEI-VFQ-25 in this population by observing the association of decrements in quality of life with levels of visual
impairment.
The purpose of this study was to determine the association
of acuity using habitual distance correction (hereafter referred
to as presenting acuity) and monocular impairment with quality-of-life-domains and to determine the individual contribution
of uncorrected refractive error, cataract, DR, and glaucoma to
decrements in quality of life in a Mexican-American group.

METHODS
Population
Proyecto VER (Vision and Eye Research Project) is a population-based
survey of visual impairment and blindness among noninstitutionalized
Hispanics, aged 40 years or more living in Nogales or Tucson, Arizona.
Sampling methods have been described elsewhere.3 In summary, a
stratified random sample of block groups were selected based on
census data of the Hispanic population in 1990. Every other household
in Nogales block groups and two of every three households in Tucson
block groups were chosen for determination of eligibility. All members
of selected households who were self-described Hispanics aged 40 or
more years were eligible to participate.

3393

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IOVS, November 2002, Vol. 43, No. 11

TABLE 1. 1996 NEI-VFQ-25

habitual distance correction. The following methods were used for

assessing visual acuity in each eye: an autorefractor (Humphrey Instruments, San Leandro, CA) was used as a starting point for full subjective
refraction. Distance acuity was tested with the Early Treatment Diabetic Retinopathy Study (ETDRS) chart17 at 3 m, illuminated at 130
cd/m2. Participants who failed to read the largest letters at 3 m were
retested at 1.5 m and then at 1 m. Visual acuity was scored as the total
number of letters read correctly, transformed to log of the minimum
angle of resolution (logMAR) units. Failure to read any letters was
assigned an acuity of 1.7 logMAR units, which is equivalent to an acuity
of 20/1000. An E chart17 was used for participants who were illiterate.
A person was considered to have uncorrected refractive error if the
difference between best-corrected and presenting acuity was more
than 2 lines.
After dilation, stereo fundus photographs of fields 1, 2, and 4 were
taken and graded for presence and severity of DR, according to the
modified Arlie House definition. For this analysis, a person with diabetes was considered to have DR if the grade exceeded 31 (moderate to
proliferative retinopathy) in at least one eye.3
An ophthalmologist examined lenses at the slit lamp. The Wilmer
grading scheme was used to grade the severity and the type of lens
opacity.18 For the purpose of this analysis, individuals were considered
to have cataract if they had a nuclear grade of 4 (the highest grade), a
cortical grade higher than 0.5, or posterior subcapsular cataract (PSC)
in at least one eye. The narrowness of the anterior chamber was also
examined at the slit lamp.
To identify glaucoma (open-angle and angle-closure), a glaucoma
specialist (HAQ) reviewed charts of persons with the following characteristics: history of glaucoma, glaucoma thought to be present by the
examining ophthalmologist, IOP of 22 mm Hg or more in either eye,
shallow anterior chamber, visual field defect, or cup-to-disc ratio of 0.7
or greater. Visual field testing was performed in each eye that had
20/200 or better visual acuity with a threshold-testing program (Swedish interactive test algorithm [SITA] Fast, 24-2 protocol of the ZeissHumphrey Humphrey Field Analyzer [HFA II] instrument, Zeiss-Humphrey Systems, Dublin, CA). Applanation tonometry was performed in
each person. Methods for diagnosing open-angle glaucoma and angleclosure glaucoma are described elsewhere.4
Blood pressure was measured three times, according to a standardized protocol.19 The average of the final two readings was used to
characterize blood pressure. Hypertension was defined as a positive
answer to the question of whether the person has hypertension and is
currently under treatment with antihypertensive medication or has
systolic pressure of 160 mm Hg or higher or diastolic blood pressure of
90 mm Hg or higher.

Subscale
General Health
General Vision
Near Vision

Distance Vision
Driving
Ocular Pain
Role Difficulties
Dependency
Social Function
Mental Health

Color Vision
Peripheral Vision

Item
Five-level health rating
Six-level vision rating
Reading ordinary print in newspapers
Work or hobbies that require you to see well
up close
Finding something on a crowded shelf
Reading street or shop signs
Going down stairs in dim light
Going out to see movies, plays, sports events
Driving during the day
Driving during the night
Eye pain keeps you from activities
Amplitude of eye pain
Accomplish less because of vision
Limited in length of activities because of
vision
Stay home because of eyesight
Rely on others because of eyesight
Need help from others because of eyesight
Seeing how people react to things you say
Visiting with people
Worry about eyesight
Worry about embarrassing myself because of
eyesight
Feel frustrated because of eyesight
Have less control of what I do because of
eyesight
Picking out and matching your clothes
Noticing objects off to the side

After obtaining informed consent for participation, the participant

was interviewed at home by trained personnel. The interview was
followed by a complete ophthalmic examination at a central clinic site.
A total of 4774 subjects participated in the interview and examination,
for a response rate of 70.1%. All study procedures were approved by
the Johns Hopkins University Joint Committee on Clinical Investigations and the University of Arizona Institutional Review Board and
complied with the tenets of the Declaration of Helsinki.

Home Interview
The questionnaire was administered by trained personnel and offered
in English and Spanish. The majority of home interviews (80%) were
conducted in Spanish. The questionnaire contained specific questions
on education, socioeconomic and health status, history of vision problems, visit to an eye care professional, and Native-American ancestry.
Also included was the NEI-VFQ-25, and a series of questions on health
care utilization, access, and insurance from the Hispanic Health and
Nutrition Examination Survey (HHANES).14 An acculturation index was
created by summarizing specific questions from HHANES regarding
preferred language, country of birth, and other questions relating to
adapting to U.S. culture.15 The acculturation score ranges from 1 to 5,
where 1 is low acculturation, and 5 is high acculturation.
The NEI-VFQ-25 is a subset of the original 51-item NEI-VFQ.16
Subscales and items for the 1996 version used in this study are shown
in Table 1. Items were answered in the following manner: amount of
difficulty, amount of time, amount true, and amplitude. Item
responses were adjusted for directionality (high scores reflect participants with good vision/health), and were rated on a scale of 0 to 100.
Subscale scores were created by averaging their adjusted item responses. Participants responses were excluded from specific items if
they had stopped the activity for reasons other than poor eyesight or
if someone other than the participant had answered the questionnaire.

Clinical Measures
Presenting and best-corrected distance acuity were measured at the
clinic. Acuity was measured in each eye with the participant using

Statistical Analysis
In previous work13 we showed that the NEI-VFQ-25 was not only
influenced by visual function, but by other demographic factors as
well: age, gender, level of acculturation, income level, education level,
location (Nogales or Tucson), and self-report of having medical insurance. These confounders were chosen because of their demonstrated
effects on self-reported quality of life in this population and their
association with eye disease. We adjusted for all these variables in the
ensuing multivariate regression models to obtain more precise estimates of the relationship of vision with quality-of-life domains. Although diabetes was an important comorbid condition in this population, the models do not include diabetes as a covariate, because of its
high association with DR; however, we adjusted for the presence of
hypertension as a representative of comorbid conditions. All covariates, except age, were modeled as categorical variables.
We used presenting acuity in the better-seeing eye to characterize
vision used on a daily basis. This approach was reasonable, because
acuity in the better eye has been shown to be as good a predictor of
self-reported functional status as other approaches of summarizing
better- and worse-eye acuity.20 We modeled presenting acuity as a
continuous variable (logMAR units) and analyzed the strength of the
association between lines lost and subscale score.

IOVS, November 2002, Vol. 43, No. 11

We also explored whether monocular impairment (presenting acuity in the worse eye worse than 20/40 and acuity in the fellow eye of
20/40 or better) influenced quality-of-life domains. Participants with
presenting acuity in the better eye of 20/40 or better were used in the
analysis, and comparisons were made between those with no impairment (both eyes had 20/40 or better acuity) and those who had
monocular impairment (one eye had worse than 20/40 acuity). In
addition, we adjusted for acuity in the better eye, because those with
monocular impairment were more likely to have lower presenting
acuity in the better eye than those without impairment.
Also assessed were the individual contributions of glaucoma, DR,
cataract, and refractive error on quality-of-life-domains. In a first model,
we assessed these additive contributions without accounting for acuity
impairment, to determine the contribution a particular disease has on
quality of life. Those with any of these eye diseases or refractive error
were compared with those with no evidence of eye disease nor
refractive error. However, eye disease per se would not be expected to
impact on quality of life unless there were an associated impact on
some aspect of vision. In a second model, we tested this hypothesis by
evaluating the additive contributions of eye disease (glaucoma, DR,
and/or cataract) on quality of life, with adjustment for presenting
acuity. In a third analysis, we added to the model second-order interaction terms between eye disease variables, to observe whether decrements in quality of life due to eye disease acted additively, or
whether extra decrements occurred when two diseases were present.
Participants with vision loss not due to glaucoma, DR, or cataract (e.g.,
macular degeneration, amblyopia, trauma) were excluded from these
analyses because there were small numbers of people in these categories.
Because the data are from a cross-sectional sample, all inferences
regarding the relationship of acuity and quality-of-life scores refer to
the comparison of quality-of-life measures between individuals with
different levels of acuity. Use of the words decrement, decline, or
loss are meant only to describe the relationship between the measures of interest, rather than to imply a longitudinal shift in quality of
life with a change in vision (or other measure).
Preliminary analysis showed that some NEI-VFQ-25 subscales had a
potentially nonlinear relationship with presenting acuity: Distance
Vision, Driving, and Mental Health. For these subscales, we allowed the
slope of presenting acuity to change for acuity worse than 20/40
(spline regression).
Subscale score distributions were skewed toward the higher scores
(e.g., ratings of excellent or no difficulty), resulting in linear model
residuals that were independent but non-normally distributed. Confidence intervals will suggest false significance, because the standard
error calculation from such models is based on residuals that are
normally distributed. To better characterize the variation of the parameter estimates, we performed a nonparametric bootstrap on all models.
A participants information was drawn at random, with replacement,
from the observed values. Estimates from the linear models were
calculated (a bootstrap estimate), and this process was repeated to
create 1000 bootstrap estimates. A 95% bias-corrected confidence
interval, was calculated, using the 2.5th and 97.5th percentiles of the
bootstrap distributions.

RESULTS
Of the 4774 participants in the study, 13 (0.3%) had questionnaires completed by proxy and 7 participants refused to undergo measurement of refraction. Of the remainder, 175 participants did not receive a complete eye disease assessment,
and 29 were diagnosed with eye disease other than glaucoma,
DR, or cataract. These latter two groups totaling 204 were
excluded from the analyses of eye disease and quality of life.
The average age for our sample was 56.9 years (range,
40 96; Table 2). Approximately two thirds of this sample had
a yearly income below $20,000 and had less than a high school

Eye Disease and Quality of Life: Proyecto VER

3395

TABLE 2. Characteristics of Mexican-American Participants in

Proyecto VER
Characteristic
Presenting acuity in
better eye
Age at time of clinic
exam (y)

Gender
Yearly income
Education
Acculturation Score

Location
Current Drivers
Medical Insurance
Hypertension
Glaucoma
Diabetic retinopathy
Cataract
Other eye disease
Uncorrected
refractive error

Category

n (%)

20/40 or better
Between 20/41 and 20/199
20/200 or worse

4368 (91.9)
363 (7.6)
23 (0.5)

4049
5059
6069
7079
80
Male
Female
$20,000
$20,000
12 years
12 years
12
23
34
44.5
Nogales
Tucson

1591 (33.4)
1361 (28.6)
982 (20.6)
631 (13.3)
195 (4.1)
1841 (38.7)
2920 (61.3)
3151 (66.2)
1492 (31.3)
3101 (65.1)
1660 (34.9)
2763 (58.0)
972 (20.4)
942 (19.8)
84 (1.8)
1620 (34.0)
3141 (66.0)
3522 (74.0)
3192 (67.1)
2085 (56.2)
100 (2.1)
290 (6.3)
374 (8.0)
29 (0.6)
405 (8.5)

n 4761 clinic participants with self-completed questionnaires,

4550 (96%) of these received complete eye examinations.

education. The participants had low acculturation scores, with

a mean of 1.99 0.95 (SD). Almost 80% chose to take the
questionnaire in Spanish.
Table 3 describes the average decrement in score for each
2 lines of presenting acuity lost for each subscale of the NEIVFQ-25. In all domains, scores showed significant decline as
the logMAR increased, after adjustment for demographic variables. The slope change was the steepest in the domains of
Role Difficulties (6.23 change in score per 2 lines lost),
Dependency (5.27 change in score per 2 lines lost), and Near
Vision (5.26 change in score per 2 lines lost). For subscales
with nonlinear associations with acuity, there were significantly steeper declines for those with vision worse than 20/40,
especially in the Driving subscale, which showed a decline of
11.6 for every 2 lines lost.
Of the 4368 participants with presenting acuity in the
better eye of 20/40 or better, 663 (15.2%) had acuity worse
than 20/40 in the other eye (monocular impairment). Those
with monocular impairment had average presenting acuity in
the better eye of 0.12 0.13 (SE) logMAR. In those with no
impairment, average presenting acuity in the better eye was
0.04 0.11 logMAR. Monocular impairment was associated
with a modest decrease in quality of life, in all domains except
General Health, Near Vision, Color Vision, and Ocular Pain
(Table 4). The greatest decrements in scores of those with
monocular impairment occurred in the visual tasks of Driving
(5.68) and General Vision (3.44), as well as in Role Function (4.43).
Subjects with cataract had mean better-eye acuity comparable to the acuity of those with glaucoma and DR (Table 5).
Most persons with cataract had PSC only (149/374; 39.8%) or

3396

Broman et al.

IOVS, November 2002, Vol. 43, No. 11

TABLE 3. Relationship of Presenting Acuity in the Better Eye to Scale Scores of The NEI-VFQ 25, Adjusting for Demographic Factors
Change in Scale Score with Addition
of 2 Lines of Acuity Loss for Acuity
Worse Than 20/40

Change in Scale Score with Addition

of 2 Lines of Acuity Loss*

NEI-VFQ Subscale

Est.

General health
General vision
Near vision
Distance vision
Driving
Peripheral vision
Color vision
Ocular pain
Role difficulties
Dependency
Social functioning
Mental health

1.84
3.60
5.26
3.78
4.49
3.77
2.67
2.67
6.23
5.27
3.39
3.66

Bootstrap
95% CI
(2.65
(4.28
(6.05
(4.61
(5.72
(4.63
(1.76
(3.52
(7.14
(6.17
(4.20
(4.73

to
to
to
to
to
to
to
to
to
to
to
to

1.10)
2.99)
4.50)
2.95)
3.33)
2.99)
3.55)
1.94)
5.31)
4.28)
2.63)
2.59)

Est.

Bootstrap
95% CI

8.60
11.65

(10.2 to 6.93)
(15.0 to 8.68)

9.00

(10.7 to 7.13)

All models are adjusted for age, gender, acculturation, income, education level, location, and medical insurance. Est., estimate.
* There is a 3-line difference between 20/20 acuity and 20/40 acuity.
For these domains, the slope changed significantly after 20/40, and we show the decline after that point (spline regression).

mixed cataract (86/374; 23.0%), with the greatest acuity impairment in those with nuclear cataract (average, 0.29 logMAR)
and mixed cataract (average, 0.36 logMAR).
After adjustment for demographic variables, those with
glaucoma, DR, cataract, and uncorrected refractive error were
found to have lower scale scores than those without disease in
general (Table 6). Those with glaucoma had significantly lower
scores in all domains except General Health and Ocular Pain
than did those with no eye disease. Those with DR had significantly lower scores in all domains. The largest decrease occurred in General Health, which was expected, because these
participants had diabetes. Those with glaucoma or DR reported larger decreases in the areas of Near and Distance
Vision, Driving, and Peripheral Vision and in the psychosocial
domains of Role Difficulties, Dependency, Social Function, and
Mental Health than did those with cataract or uncorrected
refractive error.
The association of eye disease with quality-of-life-domains
was not as strong after adjustment for presenting acuity; howTABLE 4. Degree of Decrement in Subscale Scores of Those with
Monocular Presenting Acuity Impairment, Compared with Those
with 20/40 or Better Acuity in Both Eyes
Monocular Impairment

NEI-VFQ Subscale

Est.

General health
General vision
Near vision
Distance vision
Driving
Peripheral vision
Color vision
Ocular pain
Role difficulties
Dependency
Social functioning
Mental health

0.42
3.44*
1.39
2.45*
5.68*
3.02*
0.55
0.76
4.43*
2.34*
2.08*
2.69*

Bootstrap
95% CI
(2.97
(5.03
(3.18
(4.07
(8.24
(4.92
(1.67
(2.62
(6.64
(3.99
(3.21
(4.48

to
to
to
to
to
to
to
to
to
to
to
to

1.74)
1.94)
0.54)
0.85)
3.19)
1.25)
0.45)
1.22)
2.28)
0.76)
1.03)
0.83)

All models are adjusted for presenting acuity in the better eye, age,
gender, acculturation, income, education level, location, and medical
insurance. Est., estimate.
* Indicates a significant estimate.

ever, there still were significant effects of disease (Table 7). For
glaucoma, the difference in scores after adjustment for acuity
was modest, in most cases only one point or less different from
scores that were not adjusted for acuity. For DR, the change in
scores was slightly greater (except for General Health), but still
the overall decrement in scale scores with DR was large, after
adjustment for acuity. None of the scale scores was significantly different between those with cataract and those with no
eye disease, except in Driving, after adjustment for acuity. This
suggests that the effect of cataract on quality of life in this
population was due to the effect on decreasing acuity.
The models that included interactions between glaucoma,
cataract, and DR, suggested that multiple eye disease was
associated with additional decrements in quality of life, beyond
the additive decrements associated with each disease separately. Table 8 shows the proportion of our participants with
different combinations of eye disease. After adjustment for
demographic variables, there was a significant additional decrement in score (range, 20.2 to 8.5, P 0.05) in the scales
of Near and Distant Vision, Driving, Ocular Pain, Role Function, Dependency, Mental Health, and Color Vision for those
with both glaucoma and cataract. There was a significant decrease in Driving, Role Function, and Dependency (range,
17.8 to 14.5, P 0.05) for those with glaucoma and DR,
and there was also a significant decrease in the Driving score
(8.7, P 0.04) for those with DR and cataract. However, the
number of persons with combinations of eye disease was small
and did not permit more detailed analyses.

DISCUSSION
Visual acuity impairment was significantly associated with a
decrement in all measured domains of self-reported, visionrelated quality of life in this sample of Mexican-Americans. For
TABLE 5. Comparison of Mean LogMAR Acuity in the Better Eye of
Participants with Cataract, Glaucoma, or DR
Disease

Mean Acuity

Range

Cataract
Glaucoma
DR

374
100
290

0.21
0.22
0.12

0.261.7
0.181.7
0.31.5

Eye Disease and Quality of Life: Proyecto VER

IOVS, November 2002, Vol. 43, No. 11

3397

TABLE 6. Effect of Eye Disase on NEI-VFQ-25 Scale Scores, Compared with Those with No Eye Disease, and Adjusting
for Demographic Variables
Glaucoma

NEI-VFQ Scale

Est.

General health
General vision
Near vision
Distance vision
Driving
Peripheral vision
Color vision
Ocular pain
Role difficulties
Dependency
Social functioning
Mental health

1.81
6.30*
9.01*
9.60*
17.0*
9.46*
5.78*
4.05
10.2*
14.6*
8.04*
12.7*

Diabetic Retinopathy

Bootstrap
95% CI
(7.0
(10.6
(14.5
(15.3
(28.2
(15.2
(11.1
(9.48
(13.8
(22.1
(13.1
(19.3

to
to
to
to
to
to
to
to
to
to
to
to

Est.

3.4)
1.89)
2.87)
3.62)
6.04)
3.99)
1.14)
0.49)
6.87)
7.97)
3.39)
6.95)

16.0*
4.74*
8.44*
8.64*
11.7*
6.22*
2.54*
2.92*
10.2*
8.70*
4.92*
9.73*

Bootstrap
95% CI
(18.8
(6.76
(11.4
(11.4
(15.9
(9.02
(4.77
(5.53
(13.8
(12.1
(7.14
(13.0

to
to
to
to
to
to
to
to
to
to
to
to

13.5)
2.74)
5.58)
5.90)
7.60)
3.55)
0.93)
0.23)
6.87)
5.87)
2.64)
6.46)

Uncorrected
Refractive Error

Cataract
Bootstrap
95% CI

Est.
0.09
2.74*
2.87*
3.75*
4.60*
1.62
0.83
1.22
4.40*
2.87*
1.62
3.19*

(2.65
(4.78
(5.74
(6.51
(8.54
(4.16
(2.89
(1.29
(7.53
(5.88
(3.57
(6.00

to
to
to
to
to
to
to
to
to
to
to
to

Bootstrap
95% CI

Est.

2.59)
0.88)
0.38)
1.45)
1.37)
0.67)
0.81)
3.75)
1.47)
0.51)
0.05)
0.55)

0.67
2.58*
5.07*
4.67*
3.09*
1.98
1.12
3.07*
5.51*
3.79*
1.99*
5.24*

(1.79
(4.50
(7.58
(6.80
(6.23
(3.97
(2.82
(5.60
(8.64
(6.32
(3.52
(7.86

to
to
to
to
to
to
to
to
to
to
to
to

3.73)
0.78)
2.88)
2.69)
0.07)
0.005)
0.26)
0.63)
2.88)
1.66)
0.51)
2.82)

* Indicates a significant estimate (Est.).

some physical tasks, related to driving and distance vision,

steeper decreases in scores were observed once presenting
acuity was worse than 20/40. Steeper declines in the mental
health scale were also observed. These data suggest that selfreported decrement in quality of life was present even with
modest visual loss, and that there was no threshold effect. The
finding of a modest decrement in scores among those with
monocular impairment with better-eye presenting acuity of
20/40 or better, further supports this statement.
Participants with glaucoma reported difficulties with driving and tasks of peripheral vision and feelings of dependency.
The restrictions on independent functioning imposed by driving difficulties may have contributed to reports of low scores in
dependency. The scores changed only slightly after adjustment
for acuity, which was expected because glaucoma affects peripheral field before central field. Most persons with glaucoma
do not lose central acuity until late in the course of disease
(although, in this population, glaucoma was the leading cause
of blindness21).
Participants with DR reported low scores in all domains,
especially in general health. These participants, by definition,
all had diabetes, and therefore low scores in health were
expected. It is interesting that those with DR also reported low
scores in near and distance tasks and that most of these diffi-

culties were not explained by decreased acuity. A further

analysis of the impact of DR on other measures of vision is
warranted, because decrement in ability to perform these functions may explain decrements in quality of life better than
impairment of acuity.
We have shown in previous work that the impact on selfreported physical function with loss in multiple measures of
visual function is additive.22 For example, decreases in acuity
and loss of visual fields produced additive effects on difficulties
with physical function. In this study, we observed that the impact
of cataract on quality of life was largely mediated through its
effect on acuity alone. However, glaucoma and DR probably
have other effects, apart from acuity, that have an impact on
quality of life. Our findings are consistent with our previous
work, in that those with glaucoma and DR were associated
with larger decrements in scale scores than those with cataract.
Mangione et al.12 found similar results, in that patients with
glaucoma, DR, and cataract had lower scores in all domains
than did those with no evidence of eye disease. It is interesting
that those with uncorrected refractive error reported decrements in quality of life that were comparable to decrements
reported by participants with cataract. A prospective study
would determine whether provision of adequate correction
would result in improvement in function in all these domains.

TABLE 7. Effect of Eye Disease on NEI-VFQ-25 Scale Scores, Adjusted for Presenting Acuity and Other Demographic Variables
Glaucoma

NEI-VFQ Subscale

Est.

General health
General vision
Near vision
Distance vision
Driving
Peripheral vision
Color vision
Ocular pain
Role difficulties
Dependency
Social functioning
Mental health

1.39
5.14*
7.69*
7.88*
14.8*
8.47*
5.19*
3.18
9.58*
13.0*
7.28*
10.5*

* Indicates significant estimate (Est.)

Diabetic Retinopathy

Bootstrap
95% CI
(6.49
(9.31
(12.6
(13.4
(25.4
(14.0
(10.4
(8.57
(15.4
(20.3
(12.0
(16.4

to
to
to
to
to
to
to
to
to
to
to
to

3.87)
1.21)
2.10)
2.68)
4.32)
3.23)
0.94)
1.19)
3.63)
6.94)
2.97)
4.97)

Est.
15.6*
3.75*
6.96*
6.99*
10.1*
5.14*
1.87*
2.16
8.55*
7.28*
4.07*
8.15*

Bootstrap
95% CI
(18.5
(5.68
(9.88
(9.62
(14.4
(7.92
(4.04
(4.70
(11.7
(10.4
(6.19
(11.3

to
to
to
to
to
to
to
to
to
to
to
to

13.2)
1.68)
4.24)
4.38)
6.32)
2.65)
0.26)
0.49)
5.38)
4.58)
1.99)
5.28)

Cataract

Est.
0.53
1.23
0.89
1.41
3.65*
0.17
0.09
2.35
2.03
0.84
0.45
0.62

Bootstrap
95% CI
(2.09
(3.13
(3.75
(3.93
(7.45
(2.60
(1.84
(0.12
(4.88
(3.57
(2.35
(3.24

to
to
to
to
to
to
to
to
to
to
to
to

3.20)
0.56)
1.50)
0.81)
0.38)
2.06)
1.68)
4.87)
0.97)
1.42)
1.26)
1.93)

3398

Broman et al.

IOVS, November 2002, Vol. 43, No. 11

TABLE 8. Eye Disease Categories

% of Total Sample
No eye disease
Cataract only
Diabetic retinopathy Only
Glaucoma only
Cataract and DR
Cataract and glaucoma
Glaucoma and DR
Cataract, Glaucoma, and DR

85.6
6.3
5.1
1.4
0.9
0.3
0.3
0.04

3.

4.

5.

6.

Total number with complete eye assessment, 4557

Although it is reasonable to suppose that difficulties in tasks

embedded in the near distance and driving scales would be
resolved with adequate correction, the impact on psychological and social function is not clear and deserves study.
Having more than one eye disease appeared to have a
multiplicative effect in most domains, especially in participants
with glaucoma and cataract. This finding suggests that removing cataract in the presence of other eye disease may significantly improve quality of life in these subjects.
A main limitation in our analysis of visual impairment and
vision-related quality of life was the availability of data only on
central acuity impairment. Clearly, visual impairment may have
multiple dimensions, such as loss of contrast sensitivity, peripheral field, stereo acuity, and other measures.23 We did not
capture other aspects of visual impairment, except for visual
fields, which were used in the diagnosis of glaucoma. Decrements in these other aspects of vision may correlate more
closely with decrements in specific domains. Also, we did not
collect detailed comorbidity information from participants. Information such as hearing loss, heart disease, arthritis, or stroke
may have been useful in also predicting declines in domains
such as Social Function and Dependency. Obviously, increasing severity of disease would have some impact on vision and
thus an increasing impact on quality of life, but we did not
make such an analysis. We also did not address disease-specific
issues, such as the effect of visual field loss on quality of life in
those with glaucoma.
In summary, our data suggest that visual acuity impairment,
in both the better- and the worse-seeing eyes, was associated with
a decrease in quality of life within the Mexican-American sample studied, and the steepness of that decrease was associated
with level of visual impairment. Uncorrected refractive error,
cataract, DR, and glaucoma all were associated with decrements
in quality of life, many not explained by the impact of acuity.
Further longitudinal studies on the impact of remediation of
vision loss on quality of life in this population are warranted.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.
18.

19.

20.

Acknowledgments
The authors thank Gary Rubin, Karen Bandeen-Roche, and the anonymous referees for their advice and input; and team of Proyecto VER for
their skill and support.

21.

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22.

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