BRIEF REPORTS

A Short Questionnaire on VisualFunction of Older Adults toSupplement Ophthalmic ExaminationBarbara E. K. Klein, MD, Ronald Klein, MD, andSusan C. Jensen, MS

PURPOSE: To estimate frequency of self-reported visualdysfunction in specific life situations.METHODS: Performance-based measures of visual func-tion were obtained during the 5-year follow-up examina-tion of the Beaver Dam Eye Study cohort. During thesubsequent yearly follow-up telephone call, four ques-tions concerning visual abilities in specific situationswere administered.RESULTS: Visual difficulties in everyday life situationswere commonly reported by adults aged 48 to 91 years,with only 17% to 35% of persons reporting excellent orvery good vision in the four specific situations related tovisual function. Visual acuity, near vision, and contrastsensitivity measures do not reflect the visual difficultiesencountered in common daily activities in our studypopulation (Spearman correlation coefficients all lessthan 0.35).CONCLUSIONS: A few simple questions about visual func-tion in common daily activities may give a clinicianinsights into patient complaints. It may be that environ-mental changes could improve self-reported visual func-tion. (Am J Ophthalmol 2000;130:350–352. © 2000by Elsevier Science Inc. All rights reserved.)

MANY OLDER PEOPLE HAVE GOOD VISUAL FUNCTION

when tested by performance-based measures, such asdistance and near visual acuity and contrast sensitivity.1,2

However, when self-assessment is used as a measure ofability, many people indicate poorer functional vision thanthe performance-based tests indicate.1 Although the Na-tional Eye Institute Visual Function Questionnaire has

been useful in large epidemiologic studies and clinicaltrials,3 it contains 51 questions and is not well suited toroutine use in clinical practice. We developed a simple setof questions that may alert the clinician to poorer visualfunction in situations that are not reflected by routineperformance-based measures in the office.

MATERIALS AND METHODS

METHODS USED TO IDENTIFY THE POPULATION AND DE-

scriptions of the population have appeared in previousreports.4 In brief, a private census of the population ofBeaver Dam, Wisconsin, was performed to identify allpersons 43 to 84 years of age. The baseline examinationoccurred between March 1, 1988, and September 14,1990, (n 5 4,926). There were 3,772 persons whoparticipated in the follow-up examination from March1, 1993, through June 14, 1995. Data from the partici-pants at this 5-year follow-up and from the yearlytelephone follow-up call, during which four specificquestions regarding visual function were asked, form thebasis for this report.

Institutional review board approval was granted andinformed consent obtained in accordance with theDeclaration of Helsinki. All procedures and interviewswere performed by a team of experienced ophthalmictechnicians who were specifically trained in the proto-cols of the study. Participants were asked to read theEarly Treatment Diabetic Retinopathy Study Chart Rwith their current prescription without covering eithereye. This is denoted as binocular acuity in the tables.Analyses were performed on the logarithm of minimal angleof resolution (logMAR) scores, but visual acuities are re-ported as Snellen equivalents.

Near vision was measured with the MNRead (Minne-sota Laboratory for Low-Vision Research, Minneapolis,Minnesota) charts at 16 inches (approximately 40 cm) foreach eye with the appropriate refraction in place.1 ThePelli-Robson letter charts were used to measure contrastsensitivity1 for each eye. The scores were assigned based onthe total number of letters correctly identified. Scores werecalculated as the logarithm of the contrast sensitivity(range, 0 to 1.95). A higher value implies better function.Near vision and contrast sensitivity were measured foreach eye with the contralateral eye shielded. We reportresults for the better eye in these tests.

Accepted for publication Apr 14, 2000.From the Department of Ophthalmology and Visual Sciences, Univer-

sity of Wisconsin Medical School, Madison, Wisconsin. This research issupported by National Institutes of Health Grant EYO6594 (R.K. andB.E.K.K.) and, in part, by the Research to Prevent Blindness (R.K.,Senior Scientific Investigator Award).

Inquiries to Barbara E. K. Klein, MD, MPH, Department of Ophthal-mology and Visual Sciences, University of Wisconsin–Madison, 610North Walnut St, 460 WARF, Madison, WI 53705-2397; fax: (608)263-0279.

© 2000 BY ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED.350 0002-9394/00/$20.00PII S0002-9394(00)00544-4

A follow-up call is made to each study participanteach year to ascertain his or her current address andcontacts. A series of four questions related to visualfunction was added to the yearly interview during theyear after the 5-year follow-up examinations. Informa-tion was collected on 3,378 of the 3,722 participants.The questions describe a situation and ask the respon-dents whether their vision is excellent, very good, good,fair, or poor in those circumstances. The situations werereading signs at night, reading a menu in a dimly litrestaurant dining room, finding a seat in a movie theaterafter the show has begun, and reading a book ornewspaper in the evening with room light. Analyseswere performed using the SAS (SAS Institute, Cary,North Carolina) software package.5

RESULTS

THE MEAN AGE OF THE POPULATION WAS 65.3 YEARS (SD 5

10.5) at the time of the follow-up eye examination.Both women and men reported poorer function for each

situation with increasing age (data not shown). Thenumber of persons reporting they no longer participated inthe specific activity (the question was not applicable)increased with age, but it varied with the activity and was

most marked for the question referring to finding a seat ina movie theater after the show had begun.

Most people in the sample (93.4%) had binocular visualacuity of 20/32 or better. Yet among these people, therewere a substantial number who reported good, fair, or poorvision in the situations we specified (even in the youngestage group; Table 1). Correlations between responses to thequestions and three performance-based measures vary, butnone is greater than 0.35 (Table 2).

DISCUSSION

THE INTERVIEWS WERE NOT CONDUCTED AT THE SAME

encounter during which the performance-based testswere conducted but occurred within the following year.During the intervening period, some of the subjects mayhave had changes in their visual systems that could thendiminish the correlations between the responses to thequestions and the measured functions. Although wewere unable to assess this possibility directly, we notethat the correlations we report related to the telephonequestionnaire are of a magnitude similar to those re-ported for associations of the same performance-basedmeasures with other self-assessed functions that wereaddressed during the same examination. Thus, the

TABLE 1. Performance-based Visual Functions Compared With Questionnaire-based Visual Functions

Questionnaire-based Visual Function*

Performance-based Visual Function

Current Binocular Visual Acuity Near Acuity Better Eye

Contrast Sensitivity Better

Eye

20/32 or

Better (%)

20/40 or

Worse (%)

20/32 or

Better (%)

20/40 or

Worse (%)

1.65 or

Worse (%)

1.70 or

Better (%)

Is your vision when: n 5 3147† n 5 174 n 5 3242 n 5 55 n 5 2700 n 5 553

reading road signs at night Excellent, very good 30.5 6.8 29.7 7.1 28.4 35.7

Good, fair, poor? 61.9 51.7 61.7 39.3 61.6 63.2

Not applicable‡ 6.4 40.3 7.5 51.8 8.6 0.7

n 5 3172 n 5 175 n 5 3266 n 5 56 n 5 2724 n 5 554

reading a menu in dim light Excellent, very good 25.6 7.4 25.0 1.8 24.1 28.7

Good, fair, poor? 71.5 73.3 71.5 75.0 72.4 70.1

Not applicable§ 2.5 18.8 3.0 23.2 3.0 1.1

n 5 3130 n 5 175 n 5 3224 n 5 56 n 5 2690 n 5 546

finding a movie seat in the dark Excellent, very good 16.9 4.6 16.6 1.8 15.3 22.6

Good, fair, poor? 42.8 29.0 42.4 23.2 41.1 49.8

Not applicable 38.6 65.9 39.3 75.0 41.9 26.2

n 5 3181 n 5 174 n 5 3274 n 5 56 n 5 2731 n 5 555

reading at night in dim light Excellent, very good 33.9 12.6 33.2 8.9 31.6 40.0

Good, fair, poor? 65.4 82.9 66.0 85.7 67.5 59.8

Not applicable 0.6 4.0 0.6 5.4 0.7 0.2

*See methods section for fuller description of the questions.†Numbers vary because of missing information. Percentages may not total 100% because of “don’t know” responses.‡Not applicable because the individual no longer performs that activity.§Not applicable reflects that the situation is no longer encountered.

BRIEF REPORTSVOL. 130, NO. 3 351

current study is in keeping with previous reports thatperformance-based measures of vision in a clinic settingmay give an incomplete description of functional vision.The addition of a few simple questions may provide theclinician with a better understanding of an individual’ssymptoms. Environmental changes (such as handheldlamps, increased ambient lights) may improve func-tional vision, even in older persons.

REFERENCES

1. Klein BEK, Klein R, Lee KE, Cruickshanks KJ. Associations ofperformance-based and self-reported measures of visual func-tion. The Beaver Dam Eye Study. Ophthalmic Epidemiol1999;6:49–60.

2. Tielsch JM, Sommer A, Witt K, et al. Blindness and visualimpairment in an American urban population. The BaltimoreEye Survey. Arch Ophthalmol 1990;108:286–290.

3. Mangione CM, Lee PP, Pitts J, Gutierrez P, Berry S, Hays RD,for the NEI-VFQ Field Investigators. Psychometric propertiesof the National Eye Institute Visual Function Questionnaire(NEI-VFQ). Arch Ophthalmol 1998;116:1496–1504.

4. Klein R, Klein BEK, Linton KLP, De Mets DL. The BeaverDam Eye Study: visual acuity. Ophthalmology 1991;98:1310–1315.

5. SAS Institute. SAS/STAT User’s Guide. Version 6, 4th ed,vol 1 and 2. Cary, NC: SAS Institute, 1986.

Epilenticular Intraocular LensImplantation in Traumatic Cataractwith a Ruptured Posterior CapsuleSima Pavlovic, MD

PURPOSE: To present a case of rapidly progressing trau-matic cataract caused by posterior capsule rupture afternonpenetrating ocular injury, as well as a surgical proce-dure to safely implant the intraocular lens in such atraumatized eye.METHODS: In a 23-year-old man with traumatic cataractand posterior lens capsule rupture, a one-piece polymeth-ylmethacrylate IOL was implanted before cataract extrac-tion into the ciliary sulcus in front of the cataractouslens. Subsequently, the cataract was removed by parsplana lensectomy.RESULTS: The surgery and postoperative course wereuneventful. Postoperative visual acuity was 20/20.CONCLUSION: We present a method of intraocular lensimplantation in cases of rapidly progressing traumaticcataract caused by posterior capsule rupture after a bluntocular trauma. (Am J Ophthalmol 2000;130:352–353. © 2000 by Elsevier Science Inc. All rightsreserved.)

POSTERIOR LENS CAPSULE RUPTURE AND CATARACT

formation have been described after a nonpenetratingocular injury.1 We present a case of rapidly progressingtraumatic cataract caused by posterior capsule rupture afternonpenetrating ocular injury, as well as a surgical proce-dure to safely implant the intraocular lens in such atraumatized eye.

● CASE REPORT: A 23-year-old man was referred to ourdepartment 5 days after a blunt trauma to his left eyebecause of rapidly progressing traumatic cataract.

Slit-lamp biomicroscopy revealed moderate (21) cellsin the anterior chamber and a total intumescent cataract.Anterior lens capsule was intact. No corneal or scleralperforation was found in the injured eye. Ultrasonographyrevealed a large rupture of the posterior capsule and lensfragments in the vitreous. Visual acuity was hand move-ment; intraocular pressure was 18 mm Hg.

Six days after the trauma, surgery was performed, con-sisting of an epilenticular intraocular lens implantation,pars plana lensectomy, and vitrectomy.

At the beginning of the operation, two paracenteseswere made at the limbus, at 6 and 12 o’clock meridian. Theanterior chamber was filled with a viscoelastic substance,

Accepted for publication April 25, 2000.From the Department of Ophthalmology, Justus-Liebig University,

Giessen, Germany.Inquiries to Sima Pavlovic, MD, Department of Ophthalmology,

Justus-Liebig University, Friedrichstr 18, 35392 Giessen, Germany; fax:0641/490361; e-mail: Sima.Pavlovic@augen.med.uni-giessen.de

TABLE 2. Spearman Correlation Coefficients* forPerformance-based Versus Questionnaire-based Visual

Functions

Questionnaire-based Visual

Function†

Performance-based Visual Function

Current

Binocular

Visual Acuity

Near

Acuity‡Contrast

Sensitivity§

Is your vision when:

reading road signs at

night excellent, very

good; good, fair, poor;

not applicable

0.34 0.31 20.28

reading a menu in dim

light excellent, very

good; good, fair, poor;

not applicable

0.24 0.27 20.20

finding a movie seat in

the dark excellent, very

good; good, fair, poor;

not applicable

0.25 0.25 20.26

reading at night in dim

light excellent, very

good; good, fair, poor;

not applicable

0.26 0.28 20.22

*All correlations are statistically significant, P # .0001.†See methods section for fuller description of the question.‡Acuity: low number indicates better vision.§Contrast sensitivity: low number indicates poorer contrast

sensitivity.

AMERICAN JOURNAL OF OPHTHALMOLOGY352 SEPTEMBER 2000