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Purpose To report the clinical outcomes of glaucoma management in patients with phacomatosis pigmentovascularis (PPV) treated over a period of 3 decades. Design Retrospective cohort study. Participants Fifty-five eyes of 38 patients (21 unilateral and 17 bilateral) with glaucoma in PPV managed at one institution between January 1990 and December 2019 with a minimum follow-up of 1 year. Methods Medical records of children with glaucoma in PPV were reviewed, and demographic and clinical data were collected. Surgical interventions included primary combined trabeculotomy-trabeculectomy (CTT), trabeculectomy with mitomycin C (MMC), and transscleral cyclophotocoagulation (TSCPC). Complete success was defined as intraocular pressure (IOP) ≥ 6 and ≤ 16 mmHg without medications and qualified success as IOP ≤ 16 mmHg with the use of up to 2 medications. Main Outcome Measures Intraocular pressure, best-corrected visual acuity (BCVA), corneal clarity, antiglaucoma medications at preoperative and postoperative visits (last visit), and complications. Results Median age was 4 months (range, 0.2–252 months) at the time of glaucoma surgery. Thirty-nine eyes (74%) had primary CTT, 10 eyes (19%) had trabeculectomy with MMC, and 4 eyes (7%) with advanced glaucoma had TSCPC. Two eyes (3.6%) received medical treatment. Preoperative IOP reduced from a mean of 25.7 ± 8.4 mmHg on 0.8 ± 0.6 medications to 14.6 ± 5.2 mmHg on 0.4 ± 0.5 medications (P 20/40. Four of 10 eyes that underwent trabeculectomy with MMC developed retinal detachment and were managed surgically; however, all of these eyes had poor visual outcomes. There was no incidence of bleb leakage, bleb-related infection, or endophthalmitis. Conclusions Combined trabeculotomy-trabeculectomy is safe and effective as a primary procedure for management of glaucoma in PPV. Trabeculectomy augmented with MMC as a second procedure was associated with a higher rate of complications.

PRECIS In this study, huge time delay was observed between first primary congenital glaucoma (PCG) symptom recognition by parents to ophthalmological diagnosis and this delay was unchanged over time. Bilateral affliction and mean presenting intraocular pressure (IOP) remained unaltered. PURPOSE To compare the trends in presentation of patients with PCG over 3 different time periods at 10-year intervals (1998, 2008, and 2018) managed by a single surgeon at one of the largest tertiary eye care centers in South India. METHODS Retrospective analysis of 313 eyes of 172 patients diagnosed to have PCG and treated at the L V Prasad Eye Institute (LVPEI) between January and December of the 3 specified years. Data collected included age at symptom recognition and at presentation, sex, affected eye, signs and symptoms, time between onset of symptoms and diagnosis (diagnostic delay), corneal clarity, and IOP. RESULTS Of the 172 patients, 48 (27.9%), 76 (44.2%), and 48 (27.9%) belonged to 1998, 2008, and 2018, respectively. Bilateral affliction (79% to 84%) was common and there was no sex predilection. The median age at recognition of first symptoms by caregivers/parents was 1 day (interquartile range, 1 to 30), and at diagnosis was 120 days (interquartile range, 30 to 378). Overall, presentation to LVPEI was delayed by >3 months in 80 (46.5%) children, and there was no statistically significant difference in the duration of delay over time (P=0.13). There was no significant difference in the mean presenting IOP over time (P>0.05). CONCLUSIONS We provide unique single center-based information of trends in the presentation of patients with PCG over 3 decades. Diagnostic delay was common, and a large number of characteristics of patients with PCG in South India have remained unchanged, particularly, age at onset and at diagnosis and laterality.

PURPOSE To evaluate the long-term visual and surgical outcomes, and associated risk factors for poor outcomes in patients with primary congenital glaucoma (PCG). METHODS Retrospective review of medical records of children who underwent combined trabeculotomy-trabeculectomy (CTT) without mitomycin-C as the first surgical procedure by a single surgeon between January 1990 and December 2010. Success was defined as intraocular pressure (IOP)

Purpose The Caregiver's Congenital Glaucoma QoL (CarCGQoL) questionnaire was proposed as a measure of QoL of caregivers with children with primary congenital glaucoma (PCG). Support for its psychometric properties among other diagnostic groups is required for scores to be interpreted in the same manner across groups. Therefore we investigated the measurement properties and cross-diagnostic validity of the CarCGQoL questionnaire among caregivers of children with congenital cataract, retinopathy of prematurity (ROP), and blinding corneal disorders. Methods Eight hundred ninety-one caregivers (mean age, 28.3 years; 76% mothers) of children with congenital cataract (n = 407), ROP (n = 272), and blinding corneal disorders (n = 212) completed the CarCGQoL questionnaire. Rasch analysis was used to investigate the psychometric properties. Unidimensionality (by principal components analysis of residuals, PCA) was examined for each group and for pooled sample. Differential item functioning (DIF) was investigated to explore whether bias in responses to the questionnaire existed for certain subgroups as compared to the reference group (PCG). Results Across groups, six items necessitated removal because of misfit (two common and four uncommon), after which three different versions of the questionnaire emerged. Measurement precision was adequate for each group and for the pooled sample (0.80). Unidimensionality was observed, albeit with some DIF. Regardless of the level of QoL, caregivers in the pooled sample were more likely to endorse two items reflecting ability to face child's disease, and interest to pursue leisure activity, as compared with caregivers of children with PCG. Conclusions Care must be taken when data from the CarCGQoL questionnaire from different pediatric ocular conditions are pooled, given the presence of DIF between the reference group (PCG) and the pooled sample. Translational relevance When evaluating the impact of interventions on the caregiver's QoL using the CarCGQoL questionnaire in a pooled sample of pediatric ocular conditions, cross-diagnostic DIF must be taken into account.

Purpose Little is known about quality of life (QoL) and life satisfaction (LS) of treated primary congenital glaucoma (PCG) patients in adulthood. The purpose of this study was to assess the QoL and LS and their predictors among young adults treated for PCG during early childhood. Design Cross-sectional study. Participants Eighty-two participants with PCG (mean age, 22.5 years; standard deviation [SD], 4.6); 52% were male; 94% bilateral) recruited at L V Prasad Eye Institute. Methods Participants were asked to complete the 26-item World Health Organization Quality of Life–BREF (WHOQOL-BREF) questionnaire (items related to satisfaction with general health, physical, psychological, social relations, and environmental aspects) and the 5-item Satisfaction with Life Scale (SWLS) in the clinic visit. Clinical data including visual acuity (VA) and visual fields (VFs) were collated from medical records. Rasch analysis was used to optimize the psychometric properties, with higher scores indicating a higher degree of QoL and LS, for both the questionnaires. Linear regression models were used to examine associations between overall QoL and LS (in separate models), and sociodemographic and clinical variables. Main Outcome Measures The QoL and LS were measured using Rasch-transformed scores from the WHOQOL-BREF questionnaire and SWLS, respectively. Results Response rate was 93%. The overall mean (SD) Rasch-scaled scores for QoL were 0.93 (1.11) and 0.87 (1.32) for environment domain and 0.41 (1.56) logits for LS. Better QoL was significantly related to rural residence and higher education in both univariable and multivariable analyses and explained 13% variance. Higher LS was significantly related to marital status, unilateral affliction, and higher education in univariable analyses. However, multivariable regression analysis showed that only marital status was independently associated with higher LS and explained 8.8% of variance. Clinical and treatment variables (VF, surgical interventions, medications) were not independent predictors of QoL/LS. Conclusions Our results suggest that QoL and LS of treated patients with PCG during adult life are generally good and appear to be driven by factors other than clinical indices. Educational achievement appears to be linked to better QoL and LS, and clinicians should emphasize the importance and need for education in the continued care of these patients.

SIGNIFICANCE: The Indian translated and culturally adapted version of the vision-related activity limitation (VRAL) item bank is a validated instrument to assess the difficulty in performing daily activities by cataract patients and can also be used to capture self-reported changes in ability to perform daily activities after cataract surgery. PURPOSE: The purpose of this study was to document (a) translation, cross-cultural adaptation of VRAL item bank into an Indian language, and (b) its validation using Rasch analysis in a South Indian cataract population. METHODS: At the first stage, a translated Indian version of VRAL item bank was produced using recommended procedures. At the second stage, Rasch analysis was performed to investigate its psychometric properties in 787 cataract patients (mean age, 58.2 years; mean ± SD visual acuity [logMAR], 1.19 ± 0.96 at baseline in eye for surgery) including comparison with the original version. RESULTS: Post-translation equivalence of meaning was achieved, but some English phrases required cross-cultural adaptation. Subsequently, all items were appropriate for the Indian culture, and VRAL item bank demonstrated excellent measurement precision (7.39). Dimensionality assessment suggested that VRAL construct may contain other dimensions such as self-care and visual search, and mobility. Self-care and visual search formed a unidimensional measure but was highly correlated with main VRAL dimension, and the removal of its items weakened precision of the main VRAL dimension measurement. Taken together, evidence favored retaining self-care and visual search items in a larger VRAL item bank. Mobility subscale lacked adequate measurement precision, so it was not examined further; again, items were retained in VRAL scale because they strengthened its measurement properties. Majority of items (99%) did not demonstrate notable differential item functioning (>1.0 logit) by presenting visual acuity (median, 0.20 logMAR) in the better-seeing eye. CONCLUSIONS: Items in the translated Indian VRAL item bank measure the same construct as the English version and fulfilled the psychometric requirements for use in cataract patients. Refereed/Peer-reviewed

Purpose To compare the visual functioning (VF) and vision-related QoL (VRQoL) of children 8–18 years old treated for primary congenital glaucoma (PCG) and secondary childhood glaucoma. Design Cross-sectional study. Methods A total of 309 children 8–18 years old treated for PCG and secondary childhood glaucoma between 2000 and 2010 by a single pediatric glaucoma specialist were prospectively enrolled at LV Prasad Eye Institute, Hyderabad, India. Children completed 2 questionnaires, the LV Prasad Functional Vision Questionnaire–II (LVP-FVQ-II), and the Impact of Vision Impairment-Children (IVI-C) questionnaire. Rasch-calibrated scores from both these questionnaires were used to compare the VF and VFQoL between the 2 groups. Results Mean ages of the children were 12.2 and 12.6 years in the PCG (53%, median age at diagnosis = 5 months) and secondary glaucoma groups (47%, median age at diagnosis = 3 years), respectively. A majority (80%) of children had bilateral glaucoma and underwent filtering surgery (83%). Mean better eye logMAR visual acuity (VA) was comparable between PCG and secondary childhood glaucoma groups (0.49 vs 0.52, respectively; P = 0.59). Children with PCG reported significantly better VF and VRQoL than secondary childhood glaucoma patients. Unadjusted and adjusted childhood glaucoma group comparisons revealed secondary childhood glaucoma to be associated with worse VF and VRQoL compared to PCG (difference for VF, −0.83; 95% confidence interval [CI], −1.34 to 0.31; P = 0.002; 0.39; 95% CI, 0.16–0.62; P = 0.001 for VRQoL). Conclusions Results show that children with treated PCG experience significantly better VF and VRQoL than those with secondary childhood glaucoma, despite comparable VA and IOP.

Purpose Provide item calibrations estimated for the Impact of Vision Impairment (IVI) questionnaire by pooling data from several studies of people with vision impairment (VI) representing a variety of countries and causes of VI. Methods Eight data sets from six principal investigators representing responses to IVI items from 2867 VI patients were pooled for analysis. Eligible patients were 18 years or older and from Australia, India, and the United States. Rasch analysis, using the Andrich Rating Scale Model (Winsteps version 3.65), was performed on preintervention IVI responses to estimate item and person measures, reliability coefficients, and response category thresholds. Differential item functioning (DIF) analysis and analysis of variance (ANOVA) were used to examine the effects different data sets and covariates on item estimates. Results Patient age range was 18 to 103 years (median 62 years); 55% were male. Visual acuity ranged from 20/20 to no light perception and primary diagnosis was macular degeneration in 29% of patients. Item measure estimates showed good separation reliability (R2 = 0.99). DIF magnitude did not preclude use of all IVI-28 data. ANOVA showed VA (P < 0.001) and gender (P < 0.002) were predictors of visual ability. Conclusions Analysis from pooled data support the provision of calibrated IVI item measures for researchers and clinicians to use, thus better enabling direct comparisons of patients with VI. Translational Relevance Validity testing of the IVI show that we can combine disparate data sets of patient responses to calibrate item measures and response category thresholds, and provide to others for use in comparing patients across clinical trials and on an individual basis.

SIGNIFICANCE Mobile devices such as tablet computers have become widely available as mainstream devices and are also used in some schools, but there is an absence of robust information regarding the efficacy of any optical/electronic low vision device or tablet computer in supporting education of young people with low vision. PURPOSE A randomized controlled trial (RCT) is needed to measure the impact of tablet computers on education, specifically on independent access to educational material, in children and young people with low vision. We conducted a pilot RCT to determine the feasibility of conducting a full-scale trial. METHODS This was a randomized multicenter pilot trial across two sites in the United Kingdom and one site in India. Forty children and young people aged 10 to 18 years with low vision (best-corrected visual acuity for distance between

PURPOSE: To evaluate the health-related quality of life (HRQoL) of children operated for primary congenital glaucoma (PCG) using the Kidscreen-27 questionnaire. METHODS: A total of 121 children (mean age, 11.8 years; SD, 2.8 years; 51% males) with unilateral or bilateral PCG who underwent glaucoma surgery in infancy (mean duration since surgery, 10.2 years; [SD] 4.2 years) by a single surgeon at a tertiary eye care centre were administered the Kidscreen-27 questionnaire (self-or interviewer administered in a face-to-face interview) during their routine follow-up visit. We investigated the measurement properties of Kidscreen-27 questionnaire using Rasch analysis and generated interval-level estimates of HRQoL. The main outcome measure was HRQoL (i.e., Rasch-derived Kidscreen score). Multivariable linear regression analyses assessed the influence of socio-demographic and clinical variables on the HRQoL of children with PCG. RESULTS: Majority (83%) of the children had bilateral PCG and congenital type of the disease (79%). Mean presenting acuity (logMAR) in the better eye was 0.32 (SD, 0.36; median, 0.18). Rasch analysis of Kidscreen-27 questionnaire indicated need for minor modifications following which a psychometrically robust unidimensional 23-item Kidscreen questionnaire emerged. In multivariable model, age of the child was independently associated with a 32% (β = −0.24 [95% CI, −0.11, −0.36]) increase in the HRQoL score. CONCLUSIONS: Despite undergoing successful glaucoma surgery, children with PCG reported reduced HRQoL. Younger children with PCG are more likely to experience this lowered HRQoL and ophthalmologists will need to be alert to this. Efforts must be made to improve the HRQoL of children with PCG.

Purpose We developed and validated an instrument to measure the quality of life (QoL) of caregivers of children with primary congenital glaucoma (PCG): the Caregiver's Congenital Glaucoma Quality of Life (CarCGQoL) questionnaire. Methods A total of 70 caregivers of children with PCG under follow-up at a tertiary eye care center in India participated in a series of focus groups, and pre- and pilot testing phases in the development of the 45-item CarCGQoL questionnaire. Subsequently, this instrument was administered to 111 caregivers of children with PCG awaiting glaucoma surgery. Response to each item was rated on a four-category scale. Rasch analysis was used to validate the instrument's psychometric properties, such as unidimensionality (by principal components analysis [PCA] of residuals), item fit to model, measurement precision (by person separation [PS]), response category performance, differential item functioning (DIF), and targeting of items to participant's QoL. Results Categories required reorganization resulting in a shortened rating scale of 3 categories. The instrument showed misfit to the Rasch model and lacked unidimensionality. Deleting 15 items (obtained through PCA of residuals) restored unidimensionality, but additional items misfit, necessitating item reduction. In addition, 2 items showed DIF and were deleted. Finally, a 20-item CarCGQoL instrument showed good fit and unidimensionality. Targeting was good (0.69 logits) and PS was 2.51, indicating good measurement precision. Conclusions We have developed a psychometrically robust 20-item caregiver derived questionnaire, the CarCGQoL, that is a valid and reliable measure of QoL of caregivers of children with PCG. Given its brevity, it is quick and easy to administer in the clinic, and has potential for use as an outcome measure in clinical trials of treatment of PCG.

Previous reports, albeit isolated, of vision and ocular screening of athletes with intellectual disability participating in the Special Olympics, UK, indicated high rates of refractive error and ocular morbidity; however, there have been no reports of similar sports events for this population from India. This study set out to evaluate the vision profile and ocular characteristics of athletes with intellectual disability attending the Special Olympics Lions Club International Opening Eyes (SOLCIOE) event in 2012 in India.A cross-sectional study was conducted, where a protocol-based ophthalmological assessment was performed by trained optometrists at a tertiary eye care center.Overall, 172 athletes (mean age 18.6 years, 70% male) with intellectual disability participated, and 138 (80%) were able to cooperate for complete or nearly complete vision and ocular assessment. A total of 56 (32%) had never had a previous vision or ocular health status examination. A total of 46 (32%) presented with low vision (World Health Organization definition6/18 to 3/60 in the better eye), 21% needed a first or updated spectacle prescription, and 28% had significant ocular pathology as the cause of visual loss.The proportions of refractive errors and ocular disorders in athletes with intellectual disability attending the SOLCIOE program in South India are similar to those reported for able-bodied school-aged children in urban and rural India. Like that of their able-bodied peers, the visual needs of children with intellectual disability are also not adequately being met.

Introduction Low vision and blindness adversely affect education and independence of children and young people. New ‘assistive’ technologies such as tablet computers can display text in enlarged font, read text out to the user, allow speech input and conversion into typed text, offer document and spreadsheet processing and give access to wide sources of information such as the internet. Research on these devices in low vision has been limited to case series. Methods and analysis We will carry out a pilot randomised controlled trial (RCT) to assess the feasibility of a full RCT of assistive technologies for children/young people with low vision. We will recruit 40 students age 10–18 years in India and the UK, whom we will randomise 1:1 into two parallel groups. The active intervention will be Apple iPads; the control arm will be the local standard low-vision aid care. Primary outcomes will be acceptance/usage, accessibility of the device and trial feasibility measures (time to recruit children, lost to follow-up). Exploratory outcomes will be validated measures of vision-related quality of life for children/young people as well as validated measures of reading and educational outcomes. In addition, we will carry out semistructured interviews with the participants and their teachers. Ethics and dissemination NRES reference 15/NS/0068; dissemination is planned via healthcare and education sector conferences and publications, as well as via patient support organisations. Trial registration number NCT02798848; IRAS ID 179658, UCL reference 15/0570.

Background The Patient-Health Questionnaire (PHQ-9) is a widely used screening instrument for depression. Recently, its properties as a measure were investigated using Rasch analysis in an Australian population with visual impairment (VI) and it was demonstrated to possess excellent measurement properties, but the response scale required shortening (modified PHQ-9). However, further validation was recommended to substantiate its use with the growing population of VI. Therefore, we aimed to use Rasch analysis to evaluate the measurement properties of the modified PHQ-9 in an Indian population with VI. Methods 303 patients with VI (mean age 40.2 years; 71% male) referred to Vision Rehabilitation Centres were administered the PHQ-9 by trained interviewer. Rasch analysis was used to investigate the psychometric properties of the modified PHQ-9. Results Rasch analysis showed good fit to the model, no misfitting items and an acceptable person separation reliability (0.82). Dimensionality testing supported combining 9 items to create a total score. Targeting was sub-optimal (−1.30 logits); more difficult items are needed. One item (‘trouble falling asleep’) showed notable differential item functioning, DIF (1.18 logits) by duration of VI. Limitations The generalisability of these results might be restricted to patients with VI presenting to a tertiary eye care centre. Conclusions Except for DIF, the performance of the modified PHQ-9 is consistent with that of the original, albeit in a different cultural context (Indian population with VI). Clinicians/researchers can readily use the modified PHQ-9 without formal training in Rasch procedures given the provision of ready-to-use spreadsheets that convert raw to Rasch-scaled scores. However the conversions will apply only if the sample being tested is similar to that of the present study.

To validate the Indian-translated Impact of Vision Impairment for Children (IVI_C), a vision-related quality of life (VRQoL) instrument, and to investigate the effect of sociodemographic and ocular characteristics on VRQoL.The 24-item IVI_C was administered face to face to 221 children with vision impairment (VI) (mean age, 12.6 years; male, 68%) referred to the Vision Rehabilitation Centres. Rasch analysis was used to investigate the IVI_C for key indices such as measurement precision as measured by person separation (minimum recommended value, 2.0), unidimensionality (i.e., whether all the items contribute toward measurement of a single underlying construct as assessed by item fit and principal component analysis of residuals), targeting of items to participants' VRQoL (i.e., matching of item difficulty to participant ability; ideal targeting,1.0 logits). Univariate analysis was performed to determine if the person scores of IVI_C were significantly different across participant subgroups stratified by sociodemographic and ocular characteristics, including the severity of VI.The IVI_C showed misfit to the model and lacked unidimensionality. Principal component analysis confirmed the presence of an additional construct, mobility, but it did not possess adequate person separation when assessed individually. Deleting the mobility-related items restored unidimensionality, but additional items misfit, necessitating item reduction. Finally, a 17-item IVI_C possessed good measurement precision (person separation, 2.04), was unidimensional (albeit not purely), and consisted of items that fit the Rasch model and were well targeted to the participants' VRQoL (targeting 0.76 logits). There was no statistically significant difference in the VRQoL across subgroups stratified by age, sex, type of school, cause of VI, duration of vision loss, and severity of VI (p0.05 for all).The revised 17-item IVI_C is shorter and has better psychometric properties than the original version in school-aged children with VI in India, and the responses are unrelated to sociodemographic and clinical variables. Although it has the potential for use in cross-sectional and outcomes research in children with VI, caution should be exercised while interpreting the 17-item IVI_C scores given the presence of slight multidimensionality.

PURPOSE Visual impairment (VI) negatively affects quality of life (QoL). Utilities represent a way of measuring the QoL impact associated with a particular health state, like VI, and are also useful in economic evaluations of health care interventions. Utilities can be determined either directly or indirectly. Here we determine whether the Vision and Quality of Life Index, VisQoL (indirect approach), is acceptable to use in patients with VI in an urban setting in South India; whether the VisQoL utility values, derived from an Australian sample of both visually impaired and normally sighted participants, demonstrate agreement (if any) with direct utilities, determined by time trade-off (TTO), from visually impaired South Indian patients; and determine the relationship between utilities and self-reported visual disability. METHODS Three hundred forty-nine adults with VI were administered the two-item TTO item, six-item VisQoL, and the 16-item Andhra Pradesh Eye Disease-Visual Function Questionnaire (APEDS-VFQ) in a face-to-face interview. The VisQoL utilities were derived from the utility scoring algorithm. Rasch-scaled scores of the APEDS-VFQ were obtained using the conversion scores sheets. Agreement between TTO and utilities VisQoL was assessed using the Bland-Altman method. RESULTS All participants (response rate, 100%) completed the VisQoL as compared with 72% for the TTO. There was no statistically significant difference in the mean utilities from the two methods (0.65 ± 0.31 by TTO vs. 0.66 ± 0.27 by VisQoL, p = 0.67). However, the 95% limits of agreement on the Bland-Altman plot were wide (-0.65, 0.67), implying a lack of agreement between the methods. The VisQoL relates relatively strongly with APEDS-VFQ as compared with TTO (TTO vs. APEDS-VFQ, r = -0.23, VisQoL vs. APEDS-VFQ, r = -0.66, z = -6.70; p < 0.001 for both). Older participants, female, and those with less than 12 years of education had lower utilities. CONCLUSIONS The direct (TTO) and indirect (VisQoL) methods of utility evaluation tend to disagree in our patients with VI. Given the high completion rates of the VisQoL as compared with the TTO, the VisQoL may be a suitable alternative for utility assessment in an Indian population.

PURPOSE: To explore the psychometric properties of the revised Olweus Bully/Victim Questionnaire (OBVQ) in children with visual impairment (VI) using Rasch analysis. METHODS: One hundred fifty Indian children with VI between 8 and 16 years (mean age, 11.6 years; 69% male; mean acuity in the better eye of 0.80 logMAR [Snellen, 20/126]) were administered the revised OBVQ. The 40-item revised OBVQ was developed to assess victimization (i.e., being bullied) and bullying (bullying others) in normally sighted schoolchildren. Only 16 items are used for Rasch analysis and are divided into two parts: I (victimization, eight items) and II (bullying others, eight items). Separate Rasch analysis was conducted for both parts, and the psychometric properties investigated included behavior of rating scale, extent to which the items measured a single construct (unidimensionality by fit statistics and principal component analysis [PCA] of residuals); ability to discriminate among participants' victimization and bullying behaviors (measurement precision as assessed by person separation reliability [PSR] minimum recommended value, 0.80); and targeting of items to participants' victimization and bullying. RESULTS: Response categories were misused for both parts I and II, which required repair before further analysis. Measurement precision was inadequate for both parts (PSR, 0.64 for part I and 0.19 for part II), indicating poor discriminatory ability. All items fit the Rasch model well in part I, indicating unidimensionality that was further confirmed using PCA of residuals. However, an item misfit in part II that required deletion following which the remaining items fit and PCA of residuals also supported unidimensionality. Targeting was -0.58 logits for part I, indicating that the items were matched well with the participants' victimization. By comparison, targeting was suboptimal for part II (-1.97 logits). CONCLUSIONS: In its current state, the revised OBVQ is not a valid psychometric instrument to assess victimization and bullying among children with VI. Language: en

Previous Rasch analysis of the Andhra Pradesh Eye Disease Study-Visual Function Questionnaire (APEDS-VFQ) lacked comprehensiveness, specifically, dimensionality (whether it measures single/multiple constructs). Therefore, using the Rasch model this study provides a detailed assessment of psychometric properties of the APEDS-VFQ.A total of 351 visually impaired adults (mean age, 43.3 years) were verbally administered the APEDS-VFQ. Rasch analysis was used to assess the psychometric properties of the instrument.Participants could distinguish only three categories of difficulty, so response categories were reduced from five to three. A single item ("reading small prints in newspaper/magazines", infit mean square 1.54) misfit the model. The overall pattern of fit statistics for item and person measures suggested that the underlying construct (visual ability) is not unidimensional. When the items were grouped into subsets based on functional requirements (resolution, contrast sensitivity, illumination and peripheral vision) and separate person measures were estimated for each of these domains, the first principal component contained the visual ability and accounted for 72% of the variance. Item measure distributions could be divided into 18 strata, and item-separation reliability was 0.99. Person measures could be divided into three statistically distinct strata and the person-separation reliability was 0.81.The APEDS-VFQ is a precise measure of visual ability in visually impaired adults in India. Similar to other visual function questionnaires developed for the Western population, our results demonstrate that visual ability is a two-factor composite latent variable; one dimension heavily influences reading and the other most heavily influences peripheral vision (mobility).

To examine the psychometric characteristics of the World Health Organization Quality of Life instrument—modified Indian version (modified WHOQOL) and its subscales in adults with visual impairment (VI) using Rasch analysis. Cross-sectional data were of people aged ≥40 years with VI (n = 1,333) who responded to the modified WHOQOL in the Andhra Pradesh Eye Disease Study, India. Rasch analysis was used to explore the instrument and its subscales for key indices such as measurement precision by person separation reliability, PSR (i.e., discrimination between strata of participants’ health-related QOL [HRQOL], recommended minimum value 0.8), unidimensionality (i.e., measurement of a single construct), and targeting (i.e., matching of item difficulty to participants’ HRQOL). Rasch-guided iterative approach including category re-organization to enable threshold ordering and item deletion to overcome multidimensionality resulted in a unidimensional 9-item WHOQOL and a 6-item level of independence (LOI) subscale with adequate PSR (0.81 and 0.82, respectively). Targeting was sub-optimal for both (−1.58 logits for WHOQOL and −2.55 logits for the subscale). Remaining subscales were dysfunctional. The WHOQOL and LOI subscale can be improved and shortened, and the Rasch-revised versions are likely to assess the HROQL of VI patients best because of their brevity, reliability, and unidimensionality.

Aim To investigate the psychometric properties of the three scales (general functioning, psychosocial impact, visual symptoms) of the Indian vision function questionnaire (INDeVFQ) using the Rasch measurement model. Methods 236 visually impaired patients referred to vision rehabilitation centres were administered the 33item INDeVFQ. Rasch analysis was used to investigate the scales for the following properties: precision by person separation (ie, discrimination between strata of patient ability, recommended minimum value 2.0), unidimensionality (ie, measurement of a single construct) and targeting (ie, matching of item difficulty to patient ability). Results Only the general functioning scale possessed adequate measurement precision (person separation 3.49). However, it lacked unidimensionality as some items did not contribute towards the measurement of a single construct indicating a secondary dimension. This comprised seven mobility items, which formed a separate valid subscale with good targeting (� 0.57 logits). Deleting these items restored unidimensionality but a misfitting item required removal. Following this the 13 items fit and were visual functioning related. However, targeting was suboptimal (� 1.13 logits). Conclusions The general functioning scale of the INDeVFQ consists of two separate unidimensional constructs: visual functioning and mobility. Both these Rasch scaled versions with good psychometric properties are effective tools for the assessment of visually impaired patients in India.

Purpose: Many questionnaires for the measurement of visual impairment exist. One, the Houston Vision Assessment Test (HVAT), takes a different approach: the patient is asked to rate overall impairment and the proportion attributed to vision, then through multiplication the visual and non-visual (physical) impairments are calculated. The purpose of this study was to determine whether the scores derived from this approach can be considered to be measures. Methods: The participants were 193 cataract patients awaiting surgery (mean age 74.1 ± 9.8 years, 54 per cent female and 53.6 per cent were awaiting first eye surgery), who self-administered the HVAT, which consists of 10 questions, whereby impairment on each activity and the proportion attributable to vision is rated. Therefore, total, visual and physical impairments are calculated. For each question, multiplying the impairment (five response categories) by the proportion due to eyesight (five categories) gives 10 possible levels of visual impairment. Assessment of the multiplicative rating scales included frequency of category use and hierarchical ordering of response categories using category thresholds. Summary statistics of Rasch analysis were generated for the rating scale and overall questionnaire performance. Results: In the multiplicative scale, higher response categories were under-utilised and thresholds were disordered, indicating that the categories did not function as intended. Some of the dysfunction arose from disordered thresholds in the ‘proportion due to eyesight scale’, but repairing this gave little improvement to the multiplicative scale. The ill-defined nature of the disordered categories precluded further repair by combining categories. Measurement precision, as indicated by person separation reliability, was poor (0.70). Conclusion: Rasch analysis demonstrated that the categories of the multiplied rating scale of the HVAT were not ordered, as the user would expect; this precludes measurement. This provides evidence against the use of multiplicative rating scales in quality-of-life questionnaires. It would be better to use a single rating scale for each construct of interest.

Purpose: To determine whether the eight subscales of the Refractive Status and Vision Profile (RSVP) questionnaire provide valid measurement. Methods: Two hundred patients, recruited from a refractive surgery clinic and general optometric practice, self-administered the 42-item RSVP questionnaire. Psychometric properties investigated included measurement of a single construct (unidimensionality), item fit to construct, measurement precision (represented by person separation), targeting of item difficulty to patient’s quality of life (QOL), and differential item functioning. Results: Only two subscales (“concern” and “driving”) showed adequate person separation, indicating that they could discriminate patients’ QOL. However, both demonstrated poor targeting (7.02 logits for “driving” and 1.11 logits for “concern”). One-third of items in each subscale suffered from differential item functioning. Conclusions: None of the RSVP subscales are valid for assessment of QOL in patients with refractive error, thereby indicating the RSVP should be considered as a single questionnaire without subscales.

Purpose We assess parent-child agreement regarding child's health-related quality of life (HRQoL) in children operated for congenital glaucoma (CG). Methods A total of 121 children aged 8 to 18 years (mean age, 11.8 years) operated for CG (mean duration since surgery, 10.2 years) and their parents (mean age, 36.5 years) completed the child and parent versions of the Kidscreen-27 questionnaire, respectively. Psychometric properties of Kidscreen-27 were assessed using Rasch analysis, and child-parent agreement regarding child's HRQoL was investigated using the Bland-Altman limits of agreement (LoA) method. Results Minor modifications in the rating scale and deletion of few misfitting items resulted in a psychometrically robust Kidscreen-23 questionnaire. Average parental HRQoL score was higher than the child's own ratings, with a significant difference between their scores (mean ± standard deviation [SD] difference = 0.53 ± 2.58 logits, P = 0.02; lower LoA [95% CI], -4.52 [-5.31 to -3.72] and upper LoA [95% CI], 5.58 [4.79-6.38]). The range of child-parent agreement was wide and bidirectional, with parents tending to underestimate and overestimate their child's HRQoL. Younger children and girls showed greater discordance in their HRQoL with parental reports than adolescents and boys, respectively. Conclusions Discordance between CG child's self-report of HRQoL and parent's report indicate that both groups perceive the broader impact of living with CG very differently. Translational relevance The HRQoL as reported by the child with CG and by his/her parent should be viewed as being complementary, rather than interchangeable. Both assessments should be taken into account in clinical practice and research studies.

Purpose To examine the psychometric properties of the Visual Activities Questionnaire (VAQ) and each of its subscales in a modern cataract population using Rasch analysis and if flawed, to revise the VAQ and create a valid measure that maximizes its measurement properties. Setting Flinders Eye Centre, Flinders Medical Centre, Adelaide, Australia. Methods Patients with cataract in 1 or both eyes drawn from the surgical waiting list were mailed the 33-item VAQ for self-administration. The following were examined for the entire questionnaire and each subscale: whether items measured a single construct (unidimensionality), the behavior of response categories, the ability to differentiate between patients' visual abilities (person separation), matching of item difficulty to participant ability (targeting), and whether items function similarly across subgroups of participants (differential item functioning [DIF]). Results The VAQ was completed by 561 patients. Response categories were used as intended. The VAQ discriminated the visual ability of the population (person separation, 4.88) but had suboptimum targeting, misfitting items, significant multidimensionality, DIF, and 4 dysfunctional subscales. Elimination of items causing multidimensionality resulted in a reduced 13-item VAQ that met all validity criteria for satisfactory instrument performance. Only 1 valid subscale (peripheral vision) could be preserved in the 13-item VAQ. Conclusions The VAQ in its native form was multidimensional and contained subscales with poor psychometric properties. The revised unidimensional 13-item VAQ was more appropriate for application in cataract outcomes assessment. Ideally, more items should be included to improve the targeting of item difficulty to more able cataract patients.

Purpose: The Impact of Cataract Surgery (ICS) questionnaire was designed to assess cataract surgery outcomes. The aim of this study was to describe the psychometric properties of the ICS questionnaire using the Rasch model in a cataract population. Methods: Ninety-one patients waiting to undergo cataract surgery in the first or second eye at the Flinders Medical Centre, Adelaide, South Australia self-administered the four-item ICS questionnaire. Rasch analysis was performed to assess behaviour of response categories, ability to differentiate between participants’ visual abilities (person separation; minimum acceptable 2.0), if items measure a single underlying construct [i.e. unidimensionality assessed by fit statistics and further by principal components analysis (PCA)] and matching of item difficulty to participant ability (targeting; ideal

Purpose: The 5-item Cataract Symptom Score (CSS) was developed using classical test theory to determine appropriate timing for cataract surgery, its outcomes, and whether the symptoms included bother cataract patients. The purpose of this study was to investigate the psychometric properties of the 5-item CSS using Rasch analysis. Methods: Responses from 113 patients awaiting cataract surgery to the 5-item CSS (bothered by double or distorted vision, glare or halos, blurry vision, colors looking different and worsening of vision) were subjected to Rasch analysis. The use of response categories (threshold order), ability of CSS to discriminate between participants' severity of symptoms (person separation, recommended minimum value 2.0), matching of item difficulty to severity of symptoms (targeting), and ability of items to measure a single construct (unidimensionality) were investigated. Results: Participants used the response categories as intended. However person separation (1.74) was inadequate, suggest...

Purpose. To validate visual disability questionnaire (VDQ) in patients with low vision in India, and explore whether the two latent traits “importance” and “difficulty” associated with performance of daily activities are valid and independent constructs. Methods. The VDQ consisting of 25 items was administered verbally to 137 subjects with low vision aged 16 to 89 years. Responses for each item were rated for importance and difficulty using a 5-category Likert scale. Rasch analysis was used to estimate interval measures of response ratings. Results. Subjects could discriminate only three response categories for importance and difficulty. Content validity was demonstrated by good separation indices for importance (4.24 and 2.59 for the item and person parameters, respectively) and difficulty ratings (7.64 and 3.33, respectively). High reliability scores were recorded for importance (0.95 and 0.87) and difficulty ratings (0.98 and 0.92). The most important items were “grooming” (1.15 logits) and “reading newspaper” (0.97 logits). Although “threading a needle” was the least important item (2.79 logits), it was the most difficult task (3.13 logits). The least difficult item was moving around in familiar places (2.51 logits). A poor correlation was observed between the item measures (r 0.19, p 0.34) and also between person measures (r 0.18, p 0.03) of importance and difficulty. Conclusions. The VDQ is a valid questionnaire with importance and difficulty ratings found to be independent constructs. This questionnaire could be used to prioritize the goals for rehabilitation intervention in patients with low vision. (Optom Vis Sci 2009;86:E826–E835)

PurPose: The Adaptation to Age-related Vision Loss (AVL) scale was developed to measure the adjustment of older adults who are adapting to late-life vision loss. The purpose of this study was to assess whether the AVL scale satisfies the Rasch model in a cataract population. Methods: The 24-item AVL scale (18 negatively and 6 positively coded) was mailed to 436 cataract patients for self-administration whilst they were on the waiting list for cataract surgery at the Flinders Eye Centre, Adelaide, South Australia. Rasch analysis was performed to determine whether the items were measuring a single construct (unidimensionality) as examined with fit statistics and principal components analysis (PCA) of the residuals. The ability of the scale to distinguish between the levels of adaptation of the participants (person separation) was investigated, with a value ≥ 2.0 established as the minimum acceptable. results: The AVL scale was unable to differentiate sufficiently between participants’ levels of adaptation, indicating poor person separation. One item did not fit the construct, causing misfit. Furthermore, the five positively worded items did not appear either to measure the same construct as other items, resulting in lack of unidimensionality evidenced by PCA. Following the deletion of these items, the AVL scale was one-dimensional but a single item continued to misfit, so it had to be deleted, resulting in an 18-item AVL scale. Even so, the discriminating abilities of the scale continued to be poor. ConClusions: The AVL scale is not an appropriate measure of adaptation to vision loss in a cataract population. (J Optom 2009;2:142-147 ©2009 Spanish Council of Optometry)

PURPOSE To evaluate the outcomes of multidisciplinary low vision rehabilitation (LVR) in adults with low vision (LV) in India using the Veterans Affairs Low Vision Visual Functioning Questionnaire (VA LV VFQ-48) and the Impact of Vision Impairment (IVI) questionnaire. METHODS Consecutive adults with LV referred for the first time to the Centre for Sight Enhancement were administered the 28-item IVI and VA LV VFQ-48 before and after LVR (4 months). Rasch-scaled scores were generated for the IVI and the VA LV VFQ-48 along with each of their subscales at both the time points. Effect size (ES) was calculated using Cohen's d coefficient. RESULTS Two hundred fifty-five patients completed the LVR program. Following LVR, the linear measures revealed significant improvements in vision-related quality of life (VRQoL) using the IVI at follow-up (P < 0.0001), with large ES for reading and accessing information (ES = 1.0) and relatively moderate ES for overall IVI (ES = 0.63) and mobility subscale (ES = 0.53). No significant improvement was found on emotional well-being subscale (ES = 0.18; P = 0.06). Similarly, significant improvements in VRQoL (P < 0.0001) were found for the VA LV VFQ-48 at follow-up, albeit moderate ES for the overall visual ability (ES = -0.67) and its subscales (reading [ES = -0.72], mobility [ES = -0.45], visual information [ES = -0.47), visual motor [ES = -0.54]). CONCLUSIONS Regardless of the instrument used for assessment, our multidisciplinary LVR program resulted in statistically significant improvements in visual functioning and VRQoL of those adults with LV deemed appropriate for intervention (dropout rates were high); however, the improvements were modest, and the clinical relevance of these small improvements may be limited. Nonetheless, further studies should attempt to increase the completion rates in order to draw strong inferences.

Purpose The aim of the study was (1) to determine the need for spectacles in children in Southern India with coloboma, microphthalmos and microcornea, (2) to describe their refractive errors and (3) to assess their needs for low vision aids (LVAs). Methods Children with congenital eye anomalies were recruited from special education for the blind, schools for the mentally handicapped, community-based rehabilitation programmes and hospital records in Andhra Pradesh, India. All those with at least light perception vision (PU in one eye and who had navigational vision were refracted. Those whose distance vision in their better eye improved with refraction were prescribed spectacles. Those unable to read NI0 were assessed for LVAs for near. Those with distance visual acuity of < 6/18 in the better eye were assessed for telescopes to aid distance vision. Results Ninety-nine children with coloboma, microcornea or microphthalmos had functional vision. Eight unilateral cases were excluded. Ninety-one bilateral cases were refracted and assessed for LVAs. The vision in 52 children (57%) improved in the better- seeing eye by 1 or more lines of Snellen acuity with spectacles. Spectacles were prescribed most frequently for myopia associated with choroidal coloboma. After refraction, all 19 children with a visual acuity of 6/18 or better could read NI0, and 43 of the 72 children (60%) with a visual acuity of

PURPOSE: To evaluate the extent of visual recovery after multi-disciplinary approach of treatment in serious ocular injuries; to determine the prognostic factors associated with poor final visual outcome and suggest adequate precautionary measures. METHODS: A retrospective analysis of 325 consecutive patients with direct ocular trauma who were examined and treated at a tertiary eye care centre in South India over a 3-year period was undertaken. RESULTS: Males (86.8%) outnumbered the females (13.2%) and children ( Language: en

The authors describe a case of an endocapsular hematoma that occurred in a 69-year-old Pseudophakic diabetic male following mitomycin C (MMC) augmented trabeculectomy for neovascular glaucoma (NVG). The clinical course of the patient is described, and the unique features of this case are presented and discussed. The endocapsular hematoma absorbed in 6 weeks with conservative management. The patient regained the preoperative visual acuity of 20/30, and his intraocular pressure was controlled without any glaucoma medication. The iris neovascularization regressed. This case is the first report of an endocapsular hematoma following glaucoma filtering surgery in a Pseudophakic eye with neovascular glaucoma. [Ophthalmic Surg and Lasers 1999;30:389-393.]

* BACKGROUND AND OBJECTIVE: To evaluate long-term intraocular pressure (1OP) control and visual outcome of patients with phacolytic glaucoma. * PATIENTS AND METHODS: Forty-five consecutive eyes of 45 patients with phacolytic glaucoma operated on between January 1990 and December 1995 and who had completed at least 1 year of followup were included in the study. Of the 45 eyes, 17 eyes underwent extracapsular cataract extraction (ECCE) with primary posterior chamber intraocular lens (PC IOL) implantation (group 1). The rest of the eyes (n = 28) underwent only ECCE (group 2) in view of satisfactory aphakic vision in the contralateral eye. Preoperative IOP, visual acuity, and anterior segment appearance were compared with postoperative data. * RESULTS: IOP was controlled (IOP < 21 mm Hg) in all of the patients without any antiglaucoma medication, with a mean follow-up of 29.11 ± 16.25 months (range 12 to 60) and 43.2 ± 21.5 (12 to 78) months in groups 1 and 2, respectively. The IOP remained controlled without antiglaucoma medication even in the patients where the desired visual recovery was not obtained due to glaucomatous disc damage because of delayed presentation (2 to 3 weeks or more). A visual acuity of 20/40 or better was achieved in 76.5% and 60.7% in groups 1 and 2, respectively. Eighteen of the 45 patients initially presented with light perception without projection. Eight of these 1 8 patients (44%) regained a visual acuity of 20/40 or better. There was no significant intraoperative and postoperative complication in any patient. * CONCLUSIONS: ECCE with or without primary PC IOL implantation is safe and curative in patients with phacolytic glaucoma. The addition of trabeculectomy to cataract extraction seems to be superfluous in the control of IOP in patients with phacolytic glaucoma operated on within 2 to 3 weeks of the onset of symptoms. Light perception without projection is not a contraindication for cataract surgery in phacolytic glaucoma. [Ophthalmic Surg Lasers 1998;29:880-889.]

Purpose To determine the visual success outcomes following treatment in an urban private eye hospital in India. Methods A retrospective survey was done of 4122 consecutive files of fee-paying patients admitted to a private eye hospital in Hyderabad during a 3-month period in 1996. Data obtained a minimum of 4 months after completion of treatment included age, sex, diagnosis and distance visual acuity in the best eye. Results After completion of treatment 86.5% of patients had normal vision, 10.9% had low vision and 2.5% were blind. Of the people with low vision or blindness after treatment, 81.7% had a best corrected visual acuity of between 6/18 and 6/60. The 4 most common causes of low vision after treatment were unoperated cataract (20.4%), glaucoma (13.3%), diabetic retinopathy (12.4%) and retinitis pigmentosa (10.2%). Conclusion The visual success rates in an urban Indian private eye hospital appear high with nearly 90% of patients achieving normal vision after the completion of treatment.

A healthy child was brought to our emergency department 2 h after birth with a diagnosis of suspected unilateral congenital glaucoma of the left eye. There was a history of forceps assisted delivery. Examination showed conjunctival chemosis, congestion and corneal oedema, more prominent centrally and paracentral vertical fold across the diameter of the cornea (figure 1). The right …

We determined if the Impact of Vision Impairment (IVI) is a valid questionnaire to measure the vision-related quality of life (VRQoL) in keratoconus patients, and investigated if the VRQoL varied with disease severity in this sample.WE RECRUITED 160 CONSECUTIVE BILATERAL KERATOCONUS PATIENTS (MEAN AGE 23.3 YEARS, 63% MALE) FROM AN INDIAN TERTIARY EYE CARE CENTER. PARTICIPANTS UNDERWENT A CLINICAL EXAMINATION AND COMPLETED THE IVI. PARTICIPANTS WERE DIVIDED INTO THREE GROUPS BASED ON THE AVERAGE OF THE STEEP KERATOMETRY (K) READINGS: mild (average Sim K45 diopters [D]), moderate (average Sim K 45-52 D), and severe (average Sim K52 D). Rasch analysis was used to validate the IVI and the VRQoL scores thus obtained were compared across the disease groups.THE MAJORITY (63%) OF PATIENTS HAD SEVERE, WHILE THE REMAINDER (37%) HAD MODERATE KERATOCONUS. RASCH ANALYSIS DEMONSTRATED THE VALIDITY OF THE IVI TO ASSESS VRQOL THROUGH TWO SUBSCALES: vision-specific functioning (VF) and emotional well-being (EWB). There was no significant difference in VF (mean change -0.16, P = 0.55) and EWB scores (mean change -0.32, P = 0.23) between moderate and severe keratoconus groups.The revised IVI subscales have interval-level measurement properties, which support their suitability to measure VRQoL in this keratoconus sample. Patients with moderate or severe keratoconus had similar, but higher VRQoL scores as assessed by the revised IVI subscales, indicating lack of impact of the disease on their VRQoL. However, this does not exclude the possibility of finding an impact in other populations.

Purpose The L. V. Prasad-Functional Vision Questionnaire (LVP-FVQ) was developed using Rasch analysis to assess self-reported difficulties in performing daily tasks in school children with visual impairment (VI) in India. However, the LVP-FVQ has psychometric problems of inadequate measurement precision and lack of detailed assessment of dimensionality. Furthermore, items pertaining to use of technology are lacking. The aim of this study was to present the development and validation of the second version of LVP-FVQ (LVP-FVQ II). Methods Development of LVP-FVQ II involved extracting items from other similar questionnaires (albeit developed for Western populations) and focus group discussions of children with VI and their parents that resulted in a 32-item pilot questionnaire. Overall, six items from the LVP-FVQ were retained. The questionnaire underwent pilot testing in 25 such children, following which a 27-item LVP-FVQ II emerged, and this was administered to 150 children with VI. Response to each item was rated on a three-category scale. Rasch analysis was used to validate the LVP-FVQ II. Results Rating scale was used by participants as was intended to. Four mobility-related items required deletion, as these did not contribute toward measurement of a single construct, indicating a secondary dimension. Deletion of the four items resulted in the 23-item unidimensional LVP-FVQ II, with good measurement precision, effective targeting of item difficulty to participant ability, and lack of notable differential item functioning. The LVP-FVQ II has high reliability, indicating that it is effectively able to discriminate between visual disability of school children in India, and is valid across age, gender, duration of VI, and location of residence. Conclusions Given the superior measurement properties and the interval-level scores, the LVP-FVQ II appears to offer advantages over LVP-FVQ in assessment of difficulties in performing daily tasks in this population. It can be adapted for use in other developing countries.

PURPOSE To evaluate the impact of glaucoma on visual functioning in Indians. METHODS Patients attending the glaucoma service who had undergone a comprehensive glaucoma evaluation were recruited. Better mean deviation (MD, using Humphrey Field Analyzer program 24-2) between two eyes was used to classify participants into mild, moderate, and severe visual field (VF) loss groups. Participants were administered the Glaucoma Quality of Life-15 (GQL-15) questionnaire. Rasch analysis was used to validate the GQL-15 and its four subscales. Linear regression was used to determine associations between GQL-15 scores and VF loss after adjusting for sociodemographic variables. RESULTS A total of 198 patients (mean age ± SD, 59.8 ± 12.3 years; 67% male) were recruited. Participants with severe VF loss (39%) followed by mild loss (35%) comprised the largest group. Rasch analysis resulted in a 10-item reliable and valid questionnaire: the Glaucoma Activity Limitation-10 (GAL-10). Although a single subscale, "peripheral vision," met requirements of the Rasch model, it could not be preserved in the GAL-10. In multivariate analyses, the middle-income group (compared with higher income) and severe VF-loss (compared with mild VF-loss) participants reported significantly poorer functioning on GAL-10 ([β = 0.84; 95% confidence interval (CI), 0.16-1.52; P = 0.02] and [β = 1.19; 95% CI, 0.61-1.78; P < 0.000], respectively). None of these associations were, however, clinically significant. CONCLUSIONS Glaucoma patients in India, especially those with severe VF loss, face significant challenges in performing daily tasks and in mobility. It is important to prevent progression such that activity limitation is minimized in glaucoma patients.

PURPOSE: To determine whether the Visual Symptoms and Quality of Life Questionnaire (VSQ), which was developed to be sensitive to second-eye cataract surgery, has satisfactory psychometric properties and, if so, to examine first-eye, second-eye, and bilateral cataract surgery outcomes. SETTING: Ophthalmology Clinic, Flinders Medical Centre, Adelaide, Australia. DESIGN: Cohort study. METHODS: The 26-item VSQ was self-administered by cataract patients before and after cataract surgery and by those on the cataract surgery waiting list. The VSQ was revised by Rasch analysis using preoperative questionnaire data. The surgical outcome measures were logMAR visual acuities and the Rasch-refined VSQ. RESULTS: The VSQ was self-administered by 92 patients before and after surgery (25 first eye, 38 second eye, and 29 bilateral) and by 147 on the waiting list. The preoperative visual acuity (surgical eye) was similar across groups. Cataract surgery improved visual acuities in all groups; the mean better-seeing eye visual acuity was significantly better (by 2 lines) in second and bilateral surgery patients than in first-eye surgery patients. Preoperative visual disability was significantly higher in patients awaiting cataract surgery in both eyes than in those awaiting second-eye surgery. Postoperatively, visual disability decreased significantly in all groups (first eye, 1.66 logits; second eye, 1.52 logits; bilateral, 2.58 logits). However, a floor effect limited the measurement of visual disability after cataract surgery. CONCLUSIONS: The revised visual disability scale of the VSQ measured a reduction in visual disability after first, second, and bilateral cataract surgery. However, the VSQ could not measure lower levels of visual disability, suggesting better questionnaires are required. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

This case documents unilateral congenital glaucoma associated with congenital lower lid entropion. A 2-year-old female infant was referred for evaluation and treatment of right-side buphthalmos caused by congenital glaucoma associated with bilateral congenital lower lid entropion that was prominent on the right side and present at birth. Examination disclosed a lower eyelid entropion of the right side that was treated surgically by reinserting the disinserted retractor aponeurosis to anterior inferior tarsal border. After three weeks, the patient was successfully treated with primary combined trabeculotomy-trabeculectomy for congenital glaucoma. The entropion of the left lower lid was asymptomatic and did not require any surgery. Buphthalmos caused by congenital glaucoma may be associated with congenital lower lid entropion and the association may be causal or coincidental. [Ophthalmic Surg Lasers 2001;32:149-151]

Purpose To investigate the responsiveness of 16 questionnaires used in cataract surgery outcomes. Design Prospective, observational study. Participants Patients at the Ophthalmology Eye Clinic, Flinders Medical Centre, Adelaide, Australia, and 1 matched eye clinic in Sweden. Methods Sixteen Rasch-scaled cataract surgery questionnaires were completed before and 6 months after surgery. These were: the Cataract Symptom Scale, 6 versions of the National Eye Institute Visual Function Questionnaire, the Quality of Life and Vision Function Questionnaire, the Cataract TyPE Specification, the Visual Activities Questionnaire, the Visual Disability Assessment (VDA), the Visual Function and Quality of Life questionnaire, the Visual Function Index, Catquest-9SF, the Visual Symptoms and Quality of Life questionnaire, and the Cataract Outcomes Questionnaire. Responsiveness was calculated with the effect size (ES) statistic (change in questionnaire score divided by pooled standard deviation of the preoperative and postoperative scores). Main Outcome Measures Questionnaire responsiveness to cataract surgery (ability to detect clinically important change). Results All 16 questionnaires and their subscales were responsive to cataract surgery, with visual functioning scales being more responsive than socioemotional scales and some subscales being less responsive. The largest ES was for the Catquest-9SF (1.45; 95% confidence interval [CI], 1.22–1.67), which was the only instrument with a mean and 95% CI of more than 1.0 (very large ES). Three measures had very large ESs and 95% CIs of more than 0.80 (large ES): the VDA (activity limitations and subscale) and the Cataract Outcomes Questionnaire, although their 95% CIs overlapped with a number of other instruments. Conclusions The Catquest-9SF is short and highly responsive to cataract surgery, and so is ideal for measuring visual functioning outcomes. Other instruments may be preferred to measure different constructs. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Aim The Visual Disability Assessment (VDA), a questionnaire for measuring the impact of cataract on visual functioning, was developed using classical test theory. Since this approach is limited, our aim was to further investigate the psychometric properties of the VDA using Rasch analysis. Methods 613 patients from the Flinders Medical Centre cataract surgery self-administered the VDA. Psychometric properties investigated for the overall VDA and each subscale included: measurement of a single construct (unidimensionality), item fit to the construct, reliable discrimination between strata of patient ability (person separation) and targeting of item difficulty to person ability. Results The VDA discriminated five strata of patient ability. However, seven mobility items constituted a second dimension and formed a valid separate scale. Sequestration of these items resulted in a unidimensional 11-item measure of activity limitation. Both the mobility and activity limitation scales had acceptable person separation and neither contained misfitting items. Targeting was suboptimal for mobility (−2.12 logits) but good for activity limitation (−0.72). The subscales also satisfied the requirements of the Rasch measurement model. Conclusions The Rasch-scaled VDA effectively measures two separate constructs: mobility and activity limitation (with two subscales). Its good psychometric properties make it suitable for measuring cataract surgery outcomes.

PURPOSE: To determine which version of the Visual Function Index-14 (VF-14) most precisely measured cataract surgery outcomes, rescale the VF-14 using Rasch analysis, and create a short-form version for comparison. SETTING: Flinders Medical Centre, Adelaide, South Australia, Australia. METHODS: In this cohort study incorporating questionnaire development, participants were drawn from the cataract surgery waiting list at Flinders Medical Centre. There were 2 cohorts: a preoperative cohort used for questionnaire development and an outcomes cohort. All patients had cataract surgery by phacoemulsification with intraocular lens implantation. Rasch analysis was used to refine the VF-14 into valid long-form (VF-11R) and short-form (VF-8R) versions. The ability of 8 versions (original; 2 proposed versions; 5 previously proposed versions) of the VF-14 to discriminate cataract surgery outcomes was compared with that of the standard VF-14 using the relative precision method. RESULTS: The preoperative cohort comprised 210 patients and the outcomes cohort, 51 patients. Large gains in visual functioning occurred with cataract surgery, and these were detectable with all versions of the VF-14. The largest gain in precision, 125% (relative precision. 2.25), occurred for VF-8R. Short forms that were not Rasch scaled showed gains in precision, from 23% to 80%. The VF-8R also showed the largest gains in precision in 2 subgroups: with ocular comorbidity (relative precision, 2.14) and without ocular comorbidity (relative precision, 2.48). CONCLUSIONS: Results show an unequivocal advantage to using Rasch-scaled scores for assessing cataract surgery outcomes. The 8-item, Rasch-scaled VF-8R appears ideally suited for measuring cataract surgery outcomes given its high precision and short test time. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Purpose To determine, by using Rasch analysis, whether the McMonnies questionnaire possesses the properties of a measure and whether screening for dry eye syndromes (DESs) can be enhanced by using different scoring approaches. Methods The questionnaire was self-administered by 43 female Sjogren syndrome patients (>45 years) recruited from a specialized rheumatology clinic and 140 age-matched control subjects. Data were scaled by using Rasch analysis and were assessed for response category behavior and ability to reliably discriminate between severity of the participant's dry eye symptoms (i.e., person separation reliability; minimum acceptable value, 0.80). Standard summary statistics of screening performance were calculated for raw and Rasch-scaled scores from receiver-operating characteristic analysis including area under the curve (AUC). Best predictors (i.e., questions) from a discriminant analysis were used to calculate a discriminant function for both Rasch-scaled and raw scores. Results Response categories were not used as intended, necessitating a collapse of categories. Person separation reliability was inadequate (0.75). A Rasch-scaled discriminant cutoff score of -2.29 logits from seven items provided an AUC of 0.99 with 95% sensitivity. However, discriminant raw score from modification in the scoring of a question (e.g., use of medications), used as one rather than multiple questions, provided an AUC (0.97) that was not significantly different (z = 1.11, P = 0.27), with 98% sensitivity, and required only two questions. Conclusions In this population, the McMonnies questionnaire does not function as a measure. However, various scoring methods can be used to efficiently screen for DES.

Background: The Catquest questionnaire was developed using traditional methodology to enable cataract surgery outcomes assessment in European countries. Recently, it has been validated using Rasch analysis in a Swedish population resulting in the Catquest-9SF. The aim of the present study was to assess the performance of the Catquest and the Catquest-9SF questionnaires using Rasch analysis in Australian cataract patients. Methods: A total of 217 cataract patients awaiting surgery at Flinders Medical Centre, Adelaide, South Australia self-administered the Catquest questionnaire. This is a 19-item instrument containing frequency, difficulty, symptoms and global rating items. Rasch analysis was undertaken to assess the unidimensionality (whether all the items are measuring a single underlying construct using principal components analysis or PCA), person separation (ability of the questionnaire to distinguish between strata of patient ability) and targeting of item difficulty to person ability. Results: Similar to the previous validation study, the original Catquest questionnaire required revision because of misfit and multidimensionality necessitating removal of the frequency items. The revised version was similar to the Catquest-9SF although an extra driving item was a valid optional inclusion. The Catquest-9SF performed well in the Australian cohort satisfying all criteria for valid measurement including unidimensionality. However, targeting of item difficulty to person ability was marginally worse compared with the Swedish cataract population indicating the Australian cataract patients present for surgery at lower levels of visual disability. Conclusions: The Catquest-9SF is a reliable and valid measure of visual disability in the Australian cataract population.

Purpose. To investigate the psychometric properties of the Visual Function (VF) and Quality of Life (QOL) questionnaires, using the Rasch measurement model. Methods. Four hundred eighty-nine patients with cataract awaiting surgery, drawn from the surgical waiting list of the Flinders Medical Centre, Adelaide, South Australia, were mailed the VF and QOL questionnaires for self-administration. Rasch analysis was undertaken to assess the following properties: measurement of a single construct (i.e., unidimensionality by fit statistics and principal components analysis), discrimination between strata of participant ability (person separation, recommended minimum value 2.0), targeting of item difficulty to participant ability, and differential item functioning (DIF, whether items function similarly for different subgroups and notable DIF defined as >1.0 logit). Results. The VF questionnaire fit the Rasch model showing good metric properties, including unidimensionality, and was free of notable DIF. The QOL questionnaire showed inadequate person separation, two misfitting items and significant multidimensionality (Eigenvalue of 2.3 for the first contrast), suggesting the presence of a separate subscale, self-care, but this was not valid because of inadequate person separation. Deleting these contrasting items from the QOL questionnaire removed multidimensionality and item misfit but did not improve person separation, indicating that it could not effectively discriminate between the participant’s QOL. Both VF and QOL questionnaires demonstrated poor targeting (−2.22 and −3.26 logits, respectively), indicating that items were too easy and participants had higher QOL than that the items allowed for. Three items in the QOL questionnaire demonstrated notable DIF by age and systemic comorbidity. None of the subscales functioned optimally. Conclusions. The QOL questionnaire is not a valid measure of QOL. However, the VF questionnaire is a reliable and valid measure of visual disability in patients with cataract, and although targeting was suboptimal in a developed country, it may be optimal in a developing country as was originally intended.

Aim: Previous psychometric evaluation of the Cataract Symptom Scale (CSS) focused on classic assessments of reliability and validity. The aim was to investigate the psychometric properties of the CSS using the Rasch measurement model. Methods: 243 patients drawn from the Flinders Eye Centre cataract surgery waiting-list self-administered the CSS. Rasch analysis was used to investigate the following properties of the CSS: measurement a single construct (unidimensionality), discrimination between strata of patient ability (person separation) and targeting of item difficulty to person ability. Results: The CSS discriminated between four strata of patients. However, some items did not contribute towards measurement of a single construct, indicating a secondary dimension. This comprised three mobility items, which formed a separate valid subscale. Elimination of these items resulted in the CSS being a unidimensional measure. However, further item deletion was required, as symptoms items did not measure the same construct. The resultant nine-item measure was unidimensional. Conclusions: The CSS consists of two separate unidimensional constructs: mobility and visual disability. The reduced nine-item measure has good psychometric properties and is unidimensional. The CSS is essentially a measure of visual disability, and not cataract symptoms as it is claimed to be.

Purpose: The visual functioning index (VFI) was one of the first questionnaires developed using classical test theory to assess outcomes of cataract surgery. However, it was not Rasch-validated. The objective of this study was to examine the psychometric properties of the VFI using Rasch analysis in patients with cataract. Methods: The 11-item VFI was self-administered to 243 patients (mean age 73.9 years) drawn from a cataract surgery waiting list. We examined the response category thresholds, item fit statistics, differential item functioning and unidimensionality for the VFI and its three subscales. Results: Category thresholds were ordered. The person separation and reliability were low, indicating the poor discriminatory ability of the VFI. No items misfit but there was suboptimal targeting of item difficulty to patient ability. On the whole the items in the VFI were too easy for the sample. Only one item showed moderate differential item functioning. Conclusion: The VFI does not meet the stringent requirements of the Rasch model. However adding more items to suit the more able patients with cataract as well as those awaiting second-eye cataract surgery could optimize the VFI.