Acta Ophthalmologica 2020

Vision-related quality of life and visual function in

a 70-year-old Swedish population


Lena Havstam Johansson,1,2 Dragana Skilji c,1,2 Hanna Falk Erhag,3 Felicia Ahlner,3
Christina Pernheim, Therese Rydberg Sterner,3 Hanna Wetterberg,3 Ingmar Skoog3 and
2

Madeleine Zetterberg1,2
1
Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg,
Gothenburg, Sweden
2
Department of Ophthalmology, Sahlgrenska University Hospital, M€ olndal, Sweden
3
Department of Psychiatry and Neurochemistry, Centre for Ageing and Health (AgeCap), Institute of Neuroscience and Physiology,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

ABSTRACT. Introduction
Purpose: To investigate vision-related quality of life (VRQoL), visual function
and predictors of poor vision in a population of 70-year-olds. The global over-60 population is
Methods: Self-reported ocular morbidity and responses to the National Eye increasing, and Europe has the highest
Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) in a cross- percentage of this older population,
with 25% being ≥60 years (United
sectional population study (N = 1203) in Gothenburg, Sweden, were compared
Nations 2017). Globally, 1.3 billion
with results from ophthalmic examination (N = 560).
people of all age groups live with some
Results: The most common self-reported ophthalmic morbidities were cataract form of visual impairment (VI), includ-
(23.4%), age-related macular degeneration (AMD; 4.7%), glaucoma (4.3%) ing 188.5 million with a mild distance
and diabetic retinopathy (1.4%). Cataract was more prevalent in women impairment [<0.5 decimal; 20/40 Snel-
(p = 0.001). The composite score from NEI VFQ-25 for the entire cohort was len; 0.3 logarithm of the minimum angle
91.4 (standard deviation: 27.5). When comparing composite score for different of resolution (logMAR) to ≥0.3 deci-
eye diseases, persons with cataract or AMD exhibited lower scores (p = 0.029 mal; 20/63 Snellen, 0.5 logMAR in the
and 0.018, respectively). Best-corrected visual acuity (BCVA) was normal best eye] (Bourne et al. 2017). In addi-
(≥0.5 decimal) in 98.9%; two individuals had low vision (<0.3). Men exhibited tion, 217 million are moderately to
better BCVA (median: 0.08 logMAR) than women ( 0.06; p = 0.005). severely visually impaired (between
Visual field defects were observed in 16.3% and uncorrected refractive errors <0.3 and ≥0.05 decimal; 20/400 Snellen;
in 61.5%. Poor vision was reported by 7.4% of participants with presenting 1.3 logMAR) and 36 million are blind
visual acuity (PVA) ≥0.5 (decimal), while 66.7% with PVA <0.5 reported (<0.05 decimal; 20/400 Snellen; 1.3
good vision. Of 27 individuals with PVA <0.5, 55.6% obtained a BCVA of logMAR) (Bourne et al. 2017). While
it is estimated that over 80% of global
≥1.0 with the right correction. Low contrast sensitivity was a significant
VI is treatable, the majority of individ-
predictor of experiencing poor vision (p = 0.008), while PVA and visual field
uals with VI reside in low-resource
defects were not. countries and might therefore not have
Conclusions: Low contrast sensitivity is a predictor of experiencing poor vision. access to appropriate treatment (Fricke
There is a discrepancy between subjective/objective visual function and a high et al. 2018). The leading cause of VI in
prevalence of uncorrected refractive errors. Women have more cataract, and men the world is uncorrected refractive
demonstrate slightly better visual acuity. errors (URE) (Bergman & Sjostrand
2002; Bourne et al. 2017; Thapa et al.
Key words: ageing – contrast sensitivity – cross-sectional study – gender difference – vision- 2018). Gender differences are also well
related quality of life documented, as women bear the major-
ity of VI in both low-income and high-
Acta Ophthalmol. income countries and men experience
ª 2020 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd higher vision-related quality of life
(VRQoL) in general (Chia et al. 2006).
doi: 10.1111/aos.14341

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Acta Ophthalmologica 2020
Population studies from Scandinavia
show equal proportions of visually
impaired people between countries
(Buch et al. 2001; Laitinen et al.
2010). In European countries, VI has
decreased over the last 20 years; how-
ever, caregivers need to learn more
about normal ageing and its relation-
ship to disease as well as how to identify
preventive factors and early markers for
diseases (Delcourt et al. 2018). The
leading age-related eye diseases world-
wide are cataract, age-related macular
degeneration (AMD), glaucoma and
diabetic retinopathy (Hashemi et al.
2017). Little is known about the rela-
tion between subjective and objective
visual function or the predictors asso-
ciated with experiencing low vision.
A person’s experience of VI depends
on multiple factors, and since VI often
deteriorates over a long period, it may
be difficult for the person affected to
perceive the change in visual function
(Bergman & Sjostrand 2002; Limburg
et al. 2015; Hashemi et al. 2017). Low
contrast sensitivity (CS) is an important
factor associated with decreased
VRQoL, and visual field (VF) defects
can be more limiting in daily life activ-
ities than loss of visual acuity (VA) (Roh
et al. 2018). The impact of bilateral VI is
greater than that of unilateral impair-
ment (Chia et al. 2006). Several studies
have described the relationship between
VI, eye disease and quality of life (QoL)
(Chia et al. 2006; Floriani et al. 2016;
Gerendas et al. 2018; Roh et al. 2018;
Daga et al. 2019; Petrillo et al. 2019).
General QoL questionnaires examine
non-physical aspects such as emotional,
social and existential issues and may be
used to improve care and treatment or
to help health providers to make clinical
decisions (Finger et al. 2013; Petrillo
et al. 2019). A VRQoL questionnaire
can be used in addition as a screening
device to detect eye disease or to identify
the deterioration of an existing ocular
disease (Owen et al. 2006; Gabrielian
et al. 2010; Sugar et al. 2017). People
with cataract, glaucoma, AMD and
diabetic retinopathy have lower QoL
than people without eye disease (Trento
et al. 2013). URE are common in all age
groups, although visual functioning
decreases with age (Bergman & Sjos-
trand 2002; Bourne et al. 2017; Na€el
et al. 2019). Non-refractive VI con-
tributes to greater disability than VI
due to URE, although both affect daily
life activities and lead to slower walking
2
speed as well as slower near task per-
formance (Zebardast et al. 2015).
The present study aimed to investi-
gate VRQoL, visual function and pre-
dictors of poor vision in a population
of 70-year-olds.
Materials and Methods
The study was approved by the Regio-
nal Ethical Review Board in Gothen-
burg, Sweden. The study was
performed in accordance with the
tenets of the Declaration of Helsinki,
and written informed consent was
obtained from all participants. The
sample was based on 70-year-old men
and women (n = 1203) born in 1944 on
days of the month ending with 0, 2, 5
or 8, drawn from the Gothenburg H70
Birth Cohort Study 2014–2016 in
Gothenburg, Sweden (Fig. 1) (Rydberg
Sterner et al. 2019). Inclusion criteria
were living in the urban area of
Gothenburg and being able to commu-
nicate in Swedish. Dates of birth and
residential addresses were obtained
from the Swedish Tax Agency’s popu-
lation register, which covers all citizens
in Sweden. Ophthalmic data were col-
lected in 2014 and 2015.
Vision-related quality of life and ocular
morbidity
The participants completed a question-
naire on VRQoL: the National Eye
Institute Visual Functioning Question-
naire-25 (NEI VFQ-25) version 2000,
translated into and validated in Swed-
ish (Hyman et al. 2005). NEI VFQ-25
evaluates a person’s perception of their
ocular problems by measuring the
impact of ocular diseases on broader
domains of health such as emotional
health and general well-being (Man-
gione et al. 1998). The questionnaire
generates vision-targeted subscales
such as global vision rating, difficulty
with near activities or distance activi-
ties, limitations in social functioning
due to vision, role limitations, depen-
dency on others, mental health symp-
toms due to vision, driving difficulties,
limitations in peripheral and colour
vision and ocular pain. A single general
health rating question is also included
in the questionnaire. The answers are
scored from 0 to 100, with 100 repre-
senting the best VRQoL. Items within
each subscale are averaged to create the
subscale scores according to the NEI
VFQ-25 scoring algorithm. In addition
to the NEI VFQ-25 questionnaire, the
participants answered questions on
ocular morbidity in a self-reported
questionnaire.
Visual function
Participants born on days ending with
0 or 5 (n = 560) were invited to an eye
examination which was performed by
two ophthalmic nurses at the Depart-
ment of Ophthalmology at Sahlgrenska
University Hospital (Fig. 1). The
examination included three modalities
of visual function: VA including refrac-
tion, VF and CS. Presenting VA (PVA)
and best-corrected VA (BCVA) were
measured using the Early Treatment
Diabetic Retinopathy Study logarith-
mic VA chart (Precision Vision, Wood-
stock, IL, USA) at 4 metres in
standardized light conditions. The
Topcon RM800 autorefractometer
(Topcon Medical Systems, Inc., Oak-
land, NJ, USA) was used, and spher-
ical equivalent was calculated for
refractive values. Eyes were tested sep-
arately; for analysis of objective visual
function, participants were classified
according to the vision in their best
eye. The World Health Organization
definition of normal vision was used;
≥VI 0.5 decimal, ≥20/40 Snellen and
≥0.3 logMAR. The VF of each eye was
tested with the Humphrey frequency-
doubling technology FDT perimetry
(Carl Zeiss Meditec Inc., Dublin, CA,
USA). The screening programme was
used, and if there was an indication of
VF defects, we also tested with the 24-2
SITA-fast protocol in a Humphrey
HFA 2-1740i Field Analyzer (Carl
Zeiss Meditec Inc.). Defects in one or
both eyes were noted. For CS, the
Mars Letter CS Test was used monoc-
ularly and binocularly (Mars Percep-
trix Corporation, Chappaqua, NY,
USA). According to the protocol, a
value of >1.52 logarithm CS is consid-
ered normal for 70-year-olds.
Statistical analysis
To analyse the representativeness of the
sample, we compared responders with
non-responders and compared partici-
pants who underwent ophthalmic
examination with those who only
underwent the general part of the H70
study. The comparison involved
answers from the self-reported ocular
 Acta Ophthalmologica 2020

predictors. p -values for this analysis

Invited
Excluded n = 172 are given together with b-coefficient,
- Not living in Gothenburg n = 32
70-year-olds
adjusted odds ratios and 95% confi-
- Deceased n = 29
n = 1839 - Unable to communicate in Swedish n = 53 dence intervals (CI). All statistical
- Could not be traced n = 58 analyses were performed using version
25.0 of IBM SPSS Statistics for Mac-
intosh (IBM Corp, Armonk, NY,
USA), and p-values of <0.05 were
considered statistically significant.
Effective sample Declined
n = 1667 n = 464
Results
The comparison between participants
who underwent ophthalmic examina-
tion and those not invited revealed no
Total participants
significant differences between groups,
n = 1203
indicating that the examined subsample
was representative of the full cohort
(Table 1). The group of non-respon-
ders (35 women, 34 men) had a higher
proportion of self-reported cataract
(p = 0.008) than the total H70 group,
Invited to ophthalmic
Declined but there were no differences in other
examination
n = 56 self-reported morbidity, subjective
n = 630
visual function or concerns about
vision. The reasons stated for declining
ophthalmic examination were lack of
time and indifference (n = 56). Thirteen
Declined individuals did not attend the sched-
Agreed to ophthalmic
participation after Did not attend uled appointment for unknown rea-
examination
examination n = 13 sons, and one person chose to
n=1 n = 574
withdraw from participation after the
examinations (Fig. 1).

Self-reported ocular morbidity

Effective sample
n = 560
Fig. 1. Flowchart showing 70-year-old participants born in 1944 on days of the month ending in 0,
2, 5 or 8. The sample was derived from the Gerontological and Geriatric Population Studies H70
in Gothenburg, Sweden.
disease protocol as well as the second
and third questions of the NEI VFQ-25
questionnaire. The Mann–Whitney U-
test was used to compare differences
between the groups. We used Pearson’s
chi-squared test to investigate differ-
ences between genders regarding self-
reported ocular morbidity and vision
characteristics, to examine subjective
and objective visual function and to
compare proportions of low PVA and
BCVA respectively. Uncorrected
refractive errors (URE) were defined
as PVA <1.0 and an improvement of at
least one line with best correction.
Median and geometric mean were cal-
culated for BCVA, and differences
between genders were assessed with
the Mann–Whitney U-test. The scor-
ing algorithm of the NEI VFQ-25
manual 2000 was used to calculate
the subscale scores and composite
score of the NEI VFQ-25 question-
naire (Mangione et al. 1998). These
scores are presented as mean [stan-
dard deviation (SD)], with p -values
for differences between genders calcu-
lated using the independent samples t-
test. To compare VRQoL in different
self-reported eye diseases, independent
samples t-test was used with the rest
of the entire cohort as control. Binary
logistic regression was performed with
subjective poor vision as dependent
variable and PVA <0.5, poor CS
<1.52 and any VF defect as
Questions regarding ocular morbidity
were answered by 1182 people (Table 2).
The most common eye disease was
cataract (23.4%), followed by AMD
(4.7%) and glaucoma (4.3%). There
were no differences between women
and men regarding glaucoma, AMD or
diabetic retinopathy, but a significantly
higher proportion of women than men
reported a diagnosis of cataract
(p = 0.001). The self-reported frequency
of previous cataract surgery was also
higher among women, but the difference
was not significant (p = 0.07).
Visual function
The BCVA examination showed that
98.9% of the cohort had normal vision,
defined as ≥0.5 decimal (Table 3). Only
two individuals had low vision (<0.3
decimal), and one of these persons was
blind (Table 3). A total of 490 persons
(87.5%) had a BCVA of ≥1.0 decimal.
There was a gender difference in
BCVA, with women exhibiting lower

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Acta Ophthalmologica 2020

Table 1. Non-response analysis and sample representativeness of the Gothenburg H70 Birth Vision-related quality of life
Cohort Study 2014–2016
The NEI VFQ-25 questionnaire was
p-value answered by 1139 participants: 614
p-value Ophthalmic women and 525 men (Table 5).
Total H70 examination Women scored significantly lower than
population (n = 1203) (n = 560) men in the subscales for general health,
versus versus
distance activities and driving, but
Self-reported eye disease and non-responders* no examination
vision-related quality of life (n = 69) (n = 572) significantly higher than men in the
subscales for social functioning and
Have you ever been diagnosed with cataract? 0.01 0.15 colour vision (all p-values ≤ 0.01). The
Have you ever had cataract surgery? 0.06 0.26 highest scoring for both men and
Are you currently being or have you previously 0.80 0.59 women was in the dependency sub-
been treated for glaucoma? scale, while the lowest scores came
Have you ever been diagnosed with AMD? 0.74 0.17
within the general vision subscale;
Have you ever been diagnosed with diabetic 0.61 0.20
retinopathy? more specifically, in the question ‘At
Have you ever had laser treatment for diabetic 0.48 0.54 the present time, would you say your
retinopathy? eyesight using both eyes is excellent,
Vision perception, NEI VFQ-25 Question 2† 0.43 0.20 good, fair, poor, very poor or are you
Worrying about vision, NEI VFQ-25 Question 3‡ 0.70 0.30 completely blind?’ The mean composite
score of the total group was 91.4 (SD
AMD = age-related macular degeneration, NEI VFQ-25 = National Eye Institute Visual Func-
tion Questionnaire-25.
27.5), with no significant difference
* Non-responders denote those who declined examination or failed to attend. between genders. Persons with cataract
† or AMD scored significantly lower in
‘At the present time, would you say your eyesight using both eyes (using glasses or contact lenses)
is excellent, good, fair, poor or very poor?’. VRQoL than persons with glaucoma
‡
‘How much of the time do you worry about your eyesight?’. or diabetic retinopathy (Fig. 2) when
comparing the composite score. When
asked about general vision, all self-
reported eye diseases were significantly
Table 2. Self-reported ocular morbidity in 70-year-olds associated with lower scores compared
to the entire cohort.
Number and proportion stating
‘yes’, n (%) N Overall cohort Women Men p-value
Self-perception of visual function
Have you ever been diagnosed 1182 277 (23.4) 172 (27.2) 105 (19.1) 0.001
with cataract?
Even among participants with a PVA
Have you ever had cataract 1182 172 (14.6) 103 (16.3) 69 (12.6) 0.07 of ≥1.0 decimal (≥20/20 Snellen, ≤0.0
surgery? logMAR), some individuals (n = 11,
Are you currently being or have 1182 51 (4.3) 30 (4.7) 21 (3.8) 0.44 3.9%) reported poor vision (Table 6).
you previously been treated There was no gender difference in
for glaucoma? perceived vision (data not shown). In
Have you ever been diagnosed 1179 56 (4.7) 33 (5.2) 23 (4.2) 0.41 participants with low PVA (<0.3 deci-
with age-related macular
mal), 62.5% reported good visual func-
degeneration?
Have you ever been diagnosed 1180 16 (1.4) 5 (0.8) 11 (2.0) 0.07
tion with only 37.5% experiencing
with diabetic retinopathy? poor vision. In the sample who had
Have you ever had laser 1178 11 (0.9) 4 (0.6) 7 (1.3) 0.25 normal vision with their habitual cor-
treatment for diabetic rection for far distance VA
retinopathy? (PVA ≥ 0.5), 92.6% rated their eye-
sight as excellent, good or fair and
7.4% rated their vision as poor or very
poor (p < 0.001). Among those with a
median BCVA than men (0.06 versus Uncorrected refractive errors
VF defect in one or both eyes, 16.5%
0.08 logMAR; p = 0.005). Women
More than half of the group (61.5%) experienced poor vision. Of the partic-
also showed significantly worse PVA,
had URE (Table 3). With habitual dis- ipants with low CS, 71.4% reported
with 92.6% attaining ≥0.5 decimal com-
tance correction, 27 participants had a poor eyesight, while 28.6% reported
pared to 97.6% of men (p = 0.008).
VA <0.5 (Table 4). This number was good vision (p < 0.001).
There were no gender differences in
reduced to 6 individuals after appropri- Statistical analysis of predictors for
CS, VF defects or URE. Of the 361
ate refractive correction. Differences in subjectively poor vision did not
participants tested for CS, 353
PVA and BCVA were detected in 533 demonstrate any correlation between
(98.1%) had normal or supranormal
participants (Table 4). Best-corrected poor vision and either low PVA or VF
CS, while seven (1.9%) had moder-
VA (BCVA) ≥1.0 was attained in half defects (Table 7). However, low CS
ately impaired to poor CS. A VF
of the group with PVA <0.3 and 72.7% (<1.52) was a significant predictor of
defect was found in 91(16.3%) of the
of participants with PVA <1.0. experiencing poor vision (p = 0.008).
participants.

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 Acta Ophthalmologica 2020

Table 3. Visual acuity, contrast sensitivity, visual field and refraction status in 70-year-olds

Overall cohort Women Men

Characteristics n = 560 n = 295 n = 265 p-value

BCVA (decimal), n (%)

≥1.0 490 (87.5) 251 (85.1) 239 (90.2) 0.07
≥0.5 554 (98.9) 293 (99.3) 261 (98.5) 0.34
<0.3 2 (0.4) 1 (0.3) 1 (0.4) 0.94
<0.05 1 (0.2) 0 1 (0.4) 0.29
BCVA (logMAR), 0.054 (0.15) 0.045 (0.13) 0.064 (0.17) 0.14
mean (SD)
BCVA (logMAR), 0.08 ( 0.14 to 0.00) 0.06 ( 0.12 to 0.00) 0.08 ( 0.14 to 0.02) 0.005
median (IQR)
BCVA (decimal), 1.12 1.09 1.15 0.004
geometric mean

n = 533 n = 283 n = 250

PVA (decimal), n (%)

≥1.0 288 (54.0) 142 (50.2) 146 (58.4) 0.06
≥0.5 506 (94.6) 262 (92.6) 244 (97.6) 0.008
<0.3 8 (1.5) 6 (2.1) 2 (0.8) 0.2
<0.05 1 (0.2) 0 (0) 1 (0.4) 0.29

n = 361 n = 183 n = 178

Contrast sensitivity (logCS), n (%)

≥1.52 354 (98.1) 179 (97.8) 175 (98.3) 0.73
<1.52 7 (1.9) 4 (2.2) 3 (1.7)

n = 577 n = 292 n = 265

Visual field, n (%)

No defect 466 (83.7) 243 (84.2) 223 (84.2) 0.77
Defect in one or 91 (16.3) 49 (16.8) 42 (15.8)
both eyes

n = 532 n = 283 n = 249

Refraction test, n (%)

No uncorrected refractive errors 205 (38.5) 103 (36.4) 102 (41.0) 0.28
Uncorrected refractive errors 327 (61.5) 180 (63.6) 147 (59.0)

BCVA = best-corrected visual acuity, IQR = interquartile range, logCS = logarithm contrast sensitivity, logMAR = logarithm of the minimum
angle of resolution, PVA = presenting visual acuity, SD = standard deviation.

Table 4. Presenting visual acuity (PVA) and best-corrected visual acuity (BCVA) in 70-year-olds age-standardized prevalence of VI, yet
Overall cohort BCVA ≥ 1.0 BCVA < 1.0 the growth of the ageing population is
PVA N n (%) n (%) p-value causing a substantial increase in the
number of people affected. In high-
≥1.0 288 288 (100.0) 0 income regions, the prevalence of
<1.0 245 178 (72.7) 67 (27.3) <0.001 blindness is 0.5% or less. The preva-
≥0.5 506 451 (89.1) 55 (10.9) lence of blindness in older adults is on
<0.5 27 15 (55.6) 12 (44.4) <0.001
average 4% higher in developing
≥0.3 525 462 (88.0) 63 (12.0)
<0.3 8 4 (50.0) 4 (50.0) 0.001 regions of the world than in high-
≥0.05 532 466 (87.6) 66 (12.4) income regions, for example, in western
<0.05 1 0 (0) 1 (100) 0.008 sub-Saharan Africa (5.1%), eastern
sub-Saharan Africa (4.3%) and south
Asia (4%) (Bourne et al. 2017).
Discussion population is important in order to be The present study reports the demo-
able to plan future ophthalmic care and graphic vision characteristics of Swed-
Knowledge of visual function and the support for older adults. Globally, ish 70-year-olds living in the
presence of eye diseases in the older there is an ongoing reduction in the Gothenburg area, with a representative

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Acta Ophthalmologica 2020

Table 5. Subscale scores on the National Eye Institute Visual Function Questionnaire-25 (NEI were scheduled for cataract surgery in
VFQ-25) the near future. Thus, the prevalence of
cataract reported in the present study,
Overall cohort Women Men
Subscale, mean (SD) n = 1139 n = 614 n = 525 p-value 23.4%, may be slightly lower than the
actual occurrence of cataract in the
General health 58.3 (24.6) 56.7 (25.0) 60.3 (24.0) 0.01 Swedish 70-year-old population.
General vision 78.5 (15.1) 78.4 (15.2) 78.6 (15.0) 0.77 The current study confirms data
Ocular pain 91.7 (13.9) 91.4 (14.5) 92.1 (13.3) 0.39 from previous studies on the worldwide
Near activities 87.4 (15.5) 87.5 (15.7) 87.2 (15.3) 0.75 leading causes of VI and ocular dis-
Distance activities 90.2 (13.6) 89.2 (13.8) 91.3 (13.2) 0.01
eases (Limburg et al. 2015; Hashemi
Social functioning 95.3 (10.5) 96.3 (9.7) 94.2 (11.2) 0.001
Mental health 91.6 (10.0) 91.4 (10.3) 91.8 (9.6) 0.51 et al. 2017; Thapa et al. 2018). The
Role difficulties 91.6 (14.9) 91.6 (14.6) 91.6 (15.2) 0.97 present results indicate that QoL differs
Dependency 98.5 (6.4) 98.4 (6.4) 98.6 (6.4) 0.59 between eye diseases; having glaucoma
Driving 86.3 (15.9) 82.0 (17.6) 90.1 (13.2) <0.001 or diabetic retinopathy does not influ-
Colour vision 96.3 (11.5) 98.1 (7.8) 94.3 (14.5) <0.001 ence QoL as much as AMD or
Peripheral vision 89.3 (17.4) 89.1 (18.0) 89.5 (16.8) 0.71 cataract. Several epidemiologic studies
have shown that lens opacities and
n = 1128 n = 607 n = 521 cataract surgery are more common in
Composite score 91.4 (27.5) 91.9 (36.5) 90.8 (9.2) 0.71
older women than in older men, which
was confirmed in the present study
SD = standard deviation. (Klein et al. 1992; Mitchell et al. 1997;
Ostberg et al. 2006). The reason for
this gender difference has been ascribed
sample of 1203 persons from the gen- examination, ensuring representative- to a withdrawal effect caused by the
eral population. The 560 participants ness of the sample. The 69 persons who marked reduction in oestrogen levels
subjected to ophthalmic examination were invited but declined participation after menopause (Zetterberg & Celoje-
showed no differences in self-reported had a higher proportion of cataract; vic 2015). Even though a higher pro-
ocular disorders compared to the 572 some of them were already under portion of women in the present cohort
individuals who were not invited to eye ophthalmic care and stated that they reported a diagnosis of cataract, there

General Composite General Composite General Composite General Composite

vision score vision score vision sore vision score

Fig. 2. Vision-related quality of life was compared between different types of self-reported eye disease. The Visual Functioning Questionnaire-25
subscale ‘General vision’ refers to the question ‘At the present time, would you say your eyesight using both eyes is excellent, good, fair, poor, very
poor or are you completely blind?’ In addition, the composite score for all subscales was calculated and compared between different eye diseases.
Independent t-test was used for statistical analysis, and a p-value of <0.05 was considered significant.

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 Acta Ophthalmologica 2020

Table 6. Perceived vision, from responses to the National Eye Institute Visual Function vision may increase the risk of hip
Questionnaire-25 (NEI VFQ-25), compared to visual function at examination fractures (Ivers et al. 2003; Ehrlich
et al. 2019).
Experiencing Experiencing
good vision† bad vision‡ p-value The objective finding that men had
better VA correlated with the responses
Presenting visual acuity best eye, n (%) to the VRQoL questionnaire, in which
≥1.0 274 (96.1) 11 (3.9) <0.001 men rated their distance vision higher
<1.0 210 (85.7) 35 (14.3) than women. In this study, the gender
≥0.5 466 (92.6) 37 (7.4) <0.001 difference may be due to a higher
<0.5 18 (66.7) 9 (33.3)
prevalence of cataract in the female
≥0.3 479 (91.8) 43 (8.2) 0.004
<0.3 5 (62.5) 3 (37.5) population. Our data demonstrate that
Visual field, n (%) women rate their general health lower
Normal 434 (93.9) 28 (6.1) 0.001 than men, and studies show that women
Defect in one or both eyes 76 (83.5) 15 (16.5) have a higher disease burden (Malmusi
Contrast sensitivity (binocular), n (%) et al. 2012). Gender differences in NEI
≥1.52 328 (92.9) 25 (7.1) <0.001 VFQ-25 have been found in other stud-
<1.52 2 (28.6) 5 (71.4) ies, showing fewer problems in social
†
Answering ‘excellent’, ‘good’, or ‘fair’ to question 2 on the NEI VFQ-25: ‘At the present time, functioning and colour vision among
would you say your eyesight using both eyes (using glasses or contact lenses) is. . ..?’. women (Trento et al. 2013). It is not
‡
Answering ‘poor’ or ‘very poor’ to question 2 on the NEI VFQ-25: ‘At the present time, would surprising that men showed subjectively
you say your eyesight using both eyes (using glasses or contact lenses) is. . ..?’. worse colour vision than women, giving
their higher prevalence of congenital
colour defects, but poorer visual-related
social functioning is harder to explain.
National Eye Institute (NEI) VFQ-25 is
Table 7. Predictors of experiencing poor vision on the National Eye Institute Visual Function
Questionnaire-25 (NEI VFQ-25) the most frequently used ophthalmo-
logic questionnaire in the scientific com-
Predictors b-coefficient OR* 95% CI p-value munity and has been recommended for
studies in older populations in general
Presenting visual acuity best eye <0.5 1.22 3.38 0.81–14.20 0.10
(Owen et al. 2006). The questionnaire
Contrast sensitivity binocularly <1.52 2.32 10.0 1.82–50.0 0.008
gives a comprehensive assessment of VI
Any visual field defect in either eye 0.52 1.68 0.62–4.51 0.31
and its impact on QoL. Clinicians tend
CI = confidence interval, OR = odds ratio. to underestimate the impact of vision
Logistic regression with experiencing poor vision as dependent variable, that is answering ‘poor’ loss, and NEI VFQ-25 identifies the
or ‘very poor’ to question 2 on the NEI VFQ-25: ‘At the present time, would you say your eyesight different areas in which vision may
using both eyes (using glasses or contact lenses) is. . ..?’. influence QoL (Zhang et al. 2015).
* Adjusted odds ratio.
Vision-related QoL (VRQoL) question-
naires can be used to identify individuals
was no gender difference in previous Visual distance acuity was slightly with eye disease, as they assess the ability
cataract surgery. This discrepancy may better in the male participants, which is to perform vision-related daily activities
be the result of a small sample size, but consistent with recent literature around and the impact of VI in emotional and
it could also indicate gender inequity. the world (Bourne et al. 2017). A good social domains (Owen et al. 2006).
Studies on age-related cataract indicate visual function is crucial for the ageing These questionnaires can also be used
that women receive fewer surgical ser- person’s ability to live an active life. in hospital care in risk assessment for
vices and lower therapeutic effort com- For many people, the possibility of falling, since a lower score indicates
pared to the male population, even in driving a car is an important part of greater VI (Kallstrand-Eriksson et al.
high-income countries such as Sweden being able to live an independent and 2013).
(Lewallen et al. 2009; Smirthwaite outgoing life. The male portion of the The present cohort had only a small
et al. 2014). study cohort claimed less visual-related proportion of participants with low
There was no other gender difference problems with driving. In Sweden, vision, and the majority of these were
in self-reported ocular morbidity in the older people are not required to repeat unaware of their poor vision. Among
present cohort. It is noteworthy that a visual examination or to take a new individuals with PVA of <0.5 (deci-
4% of participants reported having test to retain their driving licence. In mal), 67% reported subjectively good
glaucoma but as many as 16% exhib- our cohort, 27 people in the cohort had vision. This could be attributed to
ited VF defects. This high prevalence of distance vision too low for driving a several factors. First, the progress of
VF defects will be analysed further; car, but with the right correction this VI is slow, enabling the individual to
although there were a number of peo- number was reduced to only six indi- adjust their activities to their present
ple who were found to have probable viduals. Our data show that >60% had level of visual function. Second, a
normal-tension glaucoma, they did not URE. For older people in general, it is substantial proportion of individuals
amount to 16% of the population. A important to always ensure the right with low PVA at far distance could
few participants were previously diag- refraction to minimize the risk of obtain good VA with the right correc-
nosed with previous stroke. falling, as it has been shown that poor tion, suggesting that uncorrected

7
Acta Ophthalmologica 2020
myopia – and thus the ability to read or
perform other tasks requiring good
near vision – was not compromised.
Finally, VA does not affect the experi-
ence of quality of vision as much as VF
defects or low CS. Low CS was shown
to be the major predictor of experienc-
ing poor vision in the present study,
which may indicate that CS testing
should be performed more often by
ophthalmic care providers.
Not only did the majority of indi-
viduals with low PVA state that they
were satisfied with their vision, there
were also a substantial number of
persons with good (≥0.5) or excellent
(≥1.0) PVA who experienced bad
vision: 37 (7.4%) and 11 (3.9%),
respectively. This discrepancy between
actual VA and individual satisfaction
with visual function is a phenomenon
encountered by ophthalmic care provi-
ders on a daily basis. Psychometric
profiling may be of interest to investi-
gate why many persons experience a
quality of vision that does not correlate
with visual function as measured with
clinical examination.
A strength of the study was the
extensive somatic and psychological
questionnaires as well as physical
examinations providing detailed medi-
cal history and thorough mapping of
possible associated risk factors for
poor visual function and ocular disor-
ders. Limitations of the study include
the size of the cohort. Although the
cohort was large enough to give a good
view of visual function and VRQoL in
a normal population, the low number
of people with ocular disorders and
poor vision precluded more in-depth
analysis of the low-vision cohort. In
addition, even though participants
were invited in a strictly orderly con-
secutive fashion to prevent selection
bias, individuals with severe disease or
physical disabilities may have found it
harder to participate due to the exten-
sive examinations and medical inter-
views performed in a hospital setting
and possible difficulties in accessing
these research facilities.
In conclusion, the present study on a
Swedish 70-year-old population
demonstrates that a large majority
have excellent visual potential,
although a surprisingly large propor-
tion have URE. Despite this, the large
majority are satisfied with their visual
function, even when exhibiting low
PVA due to erroneous habitual
8
correction. Men show slightly better
VA, both BCVA and PVA, and are
also somewhat more content with their
vision. Finally, CS seems to be the
most important visual modality for a
subjectively good visual function. This
study provides knowledge on subjective
and objective vision in normal ageing,
which may contribute to improved
health care for older persons.
References
Bergman B & Sjostrand J (2002): A longitudi-
nal study of visual acuity and visual reha-
bilitation needs in an urban Swedish
population followed from the ages of 70 to
97 years of age. Acta Ophthalmol Scand 80:
598–607.
Bourne RRA, Flaxman SR, Braithwaite T
et al. (2017): Magnitude, temporal trends,
and projections of the global prevalence of
blindness and distance and near vision
impairment: a systematic review and meta-
analysis. Lancet Glob Health 5: e888–e897.
Buch H, Vinding T, La Cour M & Nielsen NV
(2001): The prevalence and causes of bilat-
eral and unilateral blindness in an elderly
urban Danish population. The Copenhagen
City Eye Study. Acta Ophthalmol Scand 79:
441–449.
Chia EM, Mitchell P, Ojaimi E, Rochtchina E
& Wang JJ (2006): Assessment of vision-
related quality of life in an older population
subsample: The Blue Mountains Eye Study.
Ophthalmic Epidemiol 13: 371–377.
Daga FB, Gracitelli CPB, Diniz-Filho A &
Medeiros FA (2019): Is vision-related qual-
ity of life impaired in patients with preperi-
metric glaucoma? Br J Ophthalmol 103:
955–959.
Delcourt C, Le Goff M, von Hanno T et al.
(2018): The decreasing prevalence of nonre-
fractive visual impairment in older Euro-
peans: a meta-analysis of published and
unpublished data. Ophthalmology 125:
1149–1159.
Ehrlich JR, Hassan SE & Stagg BC (2019):
Prevalence of falls and fall-related outcomes
in older adults with self-reported vision
impairment. J Am Geriatr Soc 67: 239–245.
Finger RP, Wiedemann P, Blumhagen F, Pohl
K & Holz FG (2013): Treatment patterns,
visual acuity and quality-of-life outcomes of
the WAVE study - a noninterventional study
of ranibizumab treatment for neovascular
age-related macular degeneration in Ger-
many. Acta Ophthalmol 91: 540–546.
Floriani I, Quaranta L, Rulli E et al. (2016):
Health-related quality of life in patients with
primary open-angle glaucoma. An Italian
multicentre observational study. Acta Oph-
thalmol 94: e278–e286.
Fricke TR, Tahhan N, Resnikoff S, Papas E,
Burnett A, Ho SM, Naduvilath T & Naidoo
KS (2018): Global prevalence of presbyopia
and vision impairment from uncorrected
presbyopia: systematic review, meta-analy-
sis, and modelling. Ophthalmology 125:
1492–1499.
Gabrielian A, Hariprasad SM, Jager RD,
Green JL & Mieler WF (2010): The utility
of visual function questionnaire in the
assessment of the impact of diabetic
retinopathy on vision-related quality of life.
Eye (London, England) 24: 29–35.
Gerendas BS, Kroisamer JS, Buehl W, Rezar-
Dreindl SM, Eibenberger KM, Pablik E,
Schmidt-Erfurth U & Sacu S (2018): Corre-
lation between morphological characteristics
in spectral-domain-optical coherence
tomography, different functional tests and
a patient’s subjective handicap in acute
central serous chorioretinopathy. Acta Oph-
thalmol 96: e776–e782.
Hashemi H, Khabazkhoob M, Nabovati P,
Ostadimoghaddam H, Shafaee S, Doostdar
A & Yekta A (2017): The prevalence of age-
related eye disease in an elderly population.
Ophthalmic Epidemiol 24: 222–228.
Hyman LG, Komaroff E, Heijl A, Bengtsson
B, Leske MC; Early Manifest Glaucoma
Trial Group (2005): Treatment and vision-
related quality of life in the early manifest
glaucoma trial. Ophthalmology 112: 1505–
1513.
Ivers RQ, Cumming RG, Mitchell P, Simpson
JM & Peduto AJ (2003): Visual risk factors
for hip fracture in older people. J Am
Geriatr Soc 51: 356–363.
Kallstrand-Eriksson J, Baigi A, Buer N &
Hildingh C (2013): Perceived vision-related
quality of life and risk of falling among
community living elderly people. Scand J
Caring Sci 27: 433–439.
Klein BE, Klein R & Linton KL (1992):
Prevalence of age-related lens opacities in a
population. The Beaver Dam Eye Study.
Ophthalmology 99: 546–552.
Laitinen A, Laatikainen L, Harkanen T,
Koskinen S, Reunanen A & Aromaa A
(2010): Prevalence of major eye diseases and
causes of visual impairment in the adult
Finnish population: a nationwide popula-
tion-based survey. Acta Ophthalmol 88:
463–471.
Lewallen S, Mousa A, Bassett K & Courtright
P (2009): Cataract surgical coverage remains
lower in women. Br J Ophthalmol 93: 295–
298.
Limburg H, Espinoza R, Lansingh VC &
Silva JC (2015): Functional low vision in
adults from Latin America: findings
from population-based surveys in 15
countries. Rev Panam Salud Publica 37:
371–378.
Malmusi D, Artazcoz L, Benach J & Borrell C
(2012): Perception or real illness? How
chronic conditions contribute to gender
inequalities in self-rated health. Eur J Public
Health 22: 781–786.
Mangione CM, Lee PP, Pitts J, Gutierrez P,
Berry S & Hays RD (1998): Psychometric
properties of the National Eye Institute
Visual Function Questionnaire (NEI-VFQ).

NEI-VFQ Field Test Investigators. Arch
Ophthalmol 116: 1496–1504.
Mitchell P, Cumming RG, Attebo K & Pan-
chapakesan J (1997): Prevalence of cataract
in Australia: the Blue Mountains eye study.
Ophthalmology 104: 581–588.
Na€el V, Moreau G, Monferme S et al. (2019):
Prevalence and associated factors of uncor-
rected refractive error in older adults in a
population-based study in France. JAMA
Ophthalmol 137: 3–11.
Ostberg A, Loth A, Gustafson D & Lindblom
B (2006): Skovde cataract study: I. Preva-
lence of lens opacities in a Swedish commu-
nity. Ophthalmology 113: 970–975.
Owen CG, Rudnicka AR, Smeeth L, Evans
JR, Wormald RP & Fletcher AE (2006): Is
the NEI-VFQ-25 a useful tool in identifying
visual impairment in an elderly population?
BMC Ophthalmol 6: 24.
Petrillo J, Balcer L, Galetta S, Chai Y, Xu L &
Cadavid D (2019): Initial impairment and
recovery of vision-related functioning in
participants with acute optic neuritis from
the RENEW Trial of Opicinumab. J Neu-
roophthalmol 39: 153–160.
Roh M, Selivanova A, Shin HJ, Miller JW &
Jackson ML (2018): Visual acuity and con-
trast sensitivity are two important factors
affecting vision-related quality of life in
advanced age-related macular degeneration.
PLoS ONE 13: e0196481.
Rydberg Sterner T, Ahlner F, Blennow K et al.
(2019): The Gothenburg H70 Birth cohort
study 2014-16: design, methods and study
population. Eur J Epidemiol 34: 191–209.
Smirthwaite G, Lundstrom M, Albrecht S &
Swahnberg K (2014): Indication criteria for
cataract extraction and gender differences in
waiting time. Acta Ophthalmol 92: 432–438.
Sugar EA, Venugopal V, Thorne JE et al.
(2017): Longitudinal vision-related quality
of life for patients with noninfectious
uveitis treated with fluocinolone ace-
tonide implant or systemic corticosteroid
therapy. Ophthalmology 124: 1662–
1669.
Thapa R, Bajimaya S, Paudyal G, Khanal S,
Tan S, Thapa SS & van Rens G (2018):
Prevalence and causes of low vision and
blindness in an elderly population in Nepal:
the Bhaktapur retina study. BMC Ophthal-
mol 18: 42.
Trento M, Passera P, Trevisan M et al. (2013):
Quality of life, impaired vision and social
role in people with diabetes: a multicenter
observational study. Acta Diabetol 50: 873–
877.
United Nations DoEaSA, Population Divi-
sion (2017): World Population Prospects:
The 2017 Revision, Key Findings and
Advance Tables. Working Paper No.
ESA/P/WP/248.
World Health Organization. Blindness and
vision impairment. Available at: https://
www.who.int/news-room/fact-sheets/detail/
blindness-and-visual-impairment. (Accessed
on 11 October 2018).
Zebardast N, Swenor BK, van Landingham
SW, Massof RW, Munoz B, West SK &
Ramulu PY (2015): Comparing the impact
of refractive and nonrefractive vision loss
on functioning and disability: the salisbury
eye evaluation. Ophthalmology 122: 1102–
1110.
Zetterberg M & Celojevic D (2015): Gender
and cataract–the role of estrogen. Curr Eye
Res 40: 176–190.
Zhang S, Liang Y, Chen Y, Musch DC,
Zhang C & Wang N (2015): Utility analysis
of vision-related quality of life in patients
with glaucoma and different perceptions
from ophthalmologists. J Glaucoma 24:
508–514.
Acta Ophthalmologica 2020
Received on July 10th, 2019.
Accepted on December 4th, 2019.
Correspondence:
Madeleine Zetterberg, MD, PhD
Department of Clinical Neuroscience, Institute
of Neuroscience and Physiology
The Sahlgrenska Academy, University of
Gothenburg
SE-431 80 M€ olndal
Sweden
Tel: +46 (0) 31 342 10 00
Fax: +46 (0) 31 41 29 04
E-mail: madeleine.zetterberg@gu.se
The authors acknowledge the research nurses at the
Centre for Ageing and Health (AgeCap) at the
University of Gothenburg who distributed the self-
reported ocular morbidity questionnaire: Carina
Alklid, Nils Beckman, Rebecca Ibstedt, Fredrika
J€onsson, Margareta Lewander, Helen Liden, Axel
Sonden, Bosse Svenningsson, Birgitta Tengelin and
Malin Thorell.
The study was financed by grants from the Swedish
state under the ALF agreement between the
Swedish government and the county councils
(ALF-GBG-145921 and ALF-GBG-716681), Wal-
ter Anderson’s foundation, De Blindas V€anner, the
Swedish Research Council for Health, Working
Life and Welfare (2013-1202, AGECAP 2013-2300,
2013-2496, 2013-0475), Konung Gustav och Drot-
tning Victorias Frimurarstiftelse, Agneta Prytz-
Folkes och G€osta Folkes stiftelse, G€oteborgs
L€akares€allskap and Eivind och Elsa K:son Sylvans
stiftelse.
Presented in part at the European Society of Oph-
thalmology (SOE) Congress, Barcelona, Spain, 10–
13 June 2017, and at the annual meeting of the
Association for Research in Vision and Ophthalmol-
ogy (ARVO), Honolulu, USA, 29 April–3 May 2018.