Impact of Visual Impairment and Correction on Vision- Related Quality of Life: Comparing People with Different Levels of Visual Acuity in Indonesia

Abstract

Purpose: This study assessed the extent to which visual impairment impacts on vision-related quality of life in Indonesia, by comparing four groups of people: those with 1) normal vision, 2) corrected visual impairment, 3) uncorrected visual impairment, and 4) blindness. Method: Purposive sampling was used. There were 162 respondents, between 21 and 86 years of age. Participants with normal vision and blindness were community-dwellers in Yogyakarta, Indonesia. Those with corrected and uncorrected visual impairment were recruited from an eye clinic. This cross-sectional study used NEI VFQ-25 to assess vision-related quality of life. The total scores and 11 NEI VFQ-25 subscales scores of four respondent groups were analysed using ANOVA, followed by post-hoc analyses to reveal between group differences. Results: There was a significant difference in the NEI VFQ-25 total scores among the four respondent groups. Respondents with normal vision had the highest score and those with blindness had the lowest. There were also significant differences among the four groups for the 11 subscales. Post-hoc analyses revealed no significant difference between respondents with normal vision and corrected visual impairment in the total and 9 NEI VFQ-25 subscales. Respondents with uncorrected visual impairment and blindness had significantly lower vision-related quality of life compared to those with normal vision or corrected visual impairment in the total and 5 NEI VFQ-25 subscales, indicating that visual impairment decreases vision-related quality of life. Conclusion: Visual impairment has a detrimental impact on a person's vision-related quality of life. The negative impact of visual impairment can be minimised by correction. Failure to correct visual impairment leads to significantly lower vision-related quality of life.

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* Corresponding Author: The Maria Meiwati Widagdo, Department of Public Health, Faculty of Medicine, Universitas
Kristen Duta Wacana, Indonesia. Email address: maria_widagdo@sta.ukdw.ac.id
Impact of Visual Impairment and Correction on Vision-
Related Quality of Life: Comparing People with Dierent
Levels of Visual Acuity in Indonesia
The Maria Meiwati Widagdo1*, Yunita Rappun1, Aprilia Vetricia Gandrung1,
Edy Wibowo2
1. Department of Public Health, Faculty of Medicine, Universitas Kristen Duta Wacana, Indonesia
2. Department of Ophthalmology, Bethesda Hospital, Indonesia
ABSTRACT
Purpose: This study assessed the extent to which visual impairment impacts on
vision-related quality of life in Indonesia, by comparing four groups of people:
those with 1) normal vision, 2) corrected visual impairment, 3) uncorrected
visual impairment, and 4) blindness.
Method: Purposive sampling was used. There were 162 respondents, between
21 and 86 years of age. Participants with normal vision and blindness were
community-dwellers in Yogyakarta, Indonesia. Those with corrected and
uncorrected visual impairment were recruited from an eye clinic. This cross-
sectional study used NEI VFQ-25 to assess vision-related quality of life. The
total scores and 11 NEI VFQ-25 subscales scores of four respondent groups
were analysed using ANOVA, followed by post-hoc analyses to reveal between
group dierences.
Results: There was a signicant dierence in the NEI VFQ-25 total scores
among the four respondent groups. Respondents with normal vision had the
highest score and those with blindness had the lowest. There were also signicant
dierences among the four groups for the 11 subscales. Post-hoc analyses revealed
no signicant dierence between respondents with normal vision and corrected
visual impairment in the total and 9 NEI VFQ-25 subscales. Respondents with
uncorrected visual impairment and blindness had signicantly lower vision-
related quality of life compared to those with normal vision or corrected visual
impairment in the total and 5 NEI VFQ-25 subscales, indicating that visual
impairment decreases vision-related quality of life.
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Conclusion: Visual impairment has a detrimental impact on a person’s vision-
related quality of life. The negative impact of visual impairment can be minimised
by correction. Failure to correct visual impairment leads to signicantly lower
vision-related quality of life.
Key words: quality of life, visual acuity, blindness, visual correction, Indonesia
INTRODUCTION
The Global Burden of Diseases project, conducted in 2017, reported that blindness
and visual impairment caused 1.19% of DALYs globally (Institute for Health
Metrics and Evaluation - IHME, 2017). The World Health Organisation’s World
Report on Vision, released in 2019, estimated that the number of people with
visual impairments worldwide was 2.2 billion (WHO, 2019). The Ministry of
Health of the Republic of Indonesia reported that the population with severe
visual impairment was more than 2 million people and the number of people
with blindness was more than 900,000 (Ministry of Health, 2013).
People with visual impairments experience limitations in carrying out various
activities in their lives. They need more time to complete tasks like eating and
drinking as they have diculty in identifying food on a plate or pouring liquid into
a glass because of their visual impairment (Pardhan et al, 2015). Independence in
conducting activities of daily living decreases as the visual impairment worsens
(Christ et al, 2014). Reduced visual acuity, decreased visual eld and blurred
vision have been associated with lower quality of life (Medeiros et al, 2014; Kim
et al, 2017).
There are several studies on the prevalence of visual impairment in Indonesia.
Mahayana et al (2017) studied primary school children in 3 districts in Yogyakarta
Province and 1 district nearby to nd the prevalence of uncorrected refractive
error in urban, suburban, exurban and rural children. Sasongko et al (2017)
reported the prevalence of diabetic-related blindness of people residing in
Yogyakarta. Muhit et al (2018) examined 195 children aged 0-15 years in Sumba
and Yogyakarta to study the epidemiology of childhood blindness.
Although much is known about the number of people with visual impairment,
Indonesia still lacks studies on how visual impairment aects vision-related
quality of life. Asrorudin (2014) investigated the eect of eye diseases and visual
impairment on vision-related quality of life in a population with severe visual
impairment and blindness in Indonesia. However, no studies have compared
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vision-related quality of life between people with normal vision and people with
dierent levels of visual impairment. The comparison between subjects with
varying visual function will help elucidate the impact of visual impairment on
vision-related quality of life in Indonesia.
Objective
Unlike previous studies conducted in Indonesia, this study aimed to compare
the quality of life of people with normal vision, corrected visual impairment,
uncorrected visual impairment and blindness.
METHOD
Study Sample
For this cross-sectional study, adults aged 18 years and older were recruited
using purposive sampling.
The respondents were classied into 4 groups: Group 1 - people with normal
vision, Group 2 - people with corrected visual impairment, Group 3 – people
with visual impairment that remained uncorrected although using visual aids,
and Group 4 – people who were legally blind. Respondents in Group 2 had either
mild or moderate visual impairment, while those in Group 3 had moderate to
severe visual impairment.
Those with normal vision and blindness were community dwellers, while
participants with visual impairment were recruited from the eye clinic of Bethesda
Hospital in Yogyakarta. The respondents with blindness were clients of Badan
Sosial Mardi Wuto, a social organisation for people with low vision or blindness.
WHO denes normal vision as visual acuity of 6/6, and blindness as visual acuity
worse than 3/60 in the beer eye with best correction (WHO, 2019). Visual acuity
of respondents with visual impairment was examined by an ophthalmologist, and
people with normal vision and blindness were examined by a trained research
assistant. People with corrected visual impairment could reach 6/6 visual acuity
with visual aids. People with uncorrected visual impairment had visual acuity
below 6/6 despite the use of visual aids.
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Data Collection
Vision-related quality of life was assessed using National Eye Institute – Vision
Function Questionnaire – 25 (NEI VFQ-25). This questionnaire has been used to
measure vision-related quality of life among Asian people as well (Suzukamo et
al, 2005; Gyawali et al, 2012; Cortina and Hallak, 2015; Saboo et al, 2017; Nickels
et al, 2017). NEI VFQ-25 has 12 subscales. The total score is the sum of the 12
subscales scores. The respondents with blindness did not drive, so all of them
scored ‘0’ in the driving subscale. Multivariate ANOVA was conducted to test
the dierences of the NEI-VFQ total and 11 subscale (excluding driving) scores
among the four groups with age and sex as covariates. Post- hoc analyses using
Dunne C were conducted to nd dierences between respondent groups.
Ethics Approval
Ethical clearance was obtained from the Ethics Commiee of the Faculty of
Medicine, Universitas Kristen Duta Wacana. Detailed explanations were given to
the participants to obtain their wrien informed consent. They were assured that
the data would be kept condential and anonymity would be maintained.
RESULTS
Data was collected from 162 respondents: 41 people with normal vision (Group
1), 41 people with corrected visual impairment (Group 2), 40 people with
uncorrected visual impairment (Group 3), and 40 people with blindness (Group
4). There were 28 females and 13 males in Group 1, 25 females and 16 males in
Group 2, 19 females and 21 males in Group 3, and 26 females and 14 males in
Group 4. The mean and standard deviations of age were: 33.59 ± 7.194 years in
Group 1; 52.85 ± 14.307 years in Group 2; 60.98 ± 15.58 years in Group 3; and 46.83
± 12.09 years in Group 4.
The most common cause of visual impairment in Group 2 was cataract (61%),
followed by refractive disorders (24%) and glaucoma (7%). Cataract was also the
most common cause of visual impairment in Group 3 (65%), followed by glaucoma
(15%), diabetic retinopathy (12.5%) and age-related macular degeneration
(2.5%). Meanwhile, among respondents with blindness, measles (87.5%) was
the most common cause of blindness since childhood, followed by congenital
cataracts (7.5%) and glaucoma and retinal detachment (2.5% each) respectively.
The majority of respondents in Group 2 (85%) and Group 3 (65%) had visual
impairment for less than 5 years, while respondents in Group 4 had been blind
for more than 10 years (100%).
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Most respondents had high school education in Group 1 (47.5%) and Group
3 (62.5%). In Group 2, 52.5% had college education, while respondents with
blindness had the lowest level of education, as 27.5% had never been to school
and 50% had elementary school education.
The majority of respondents in Group 1 and Group 2 were working people (75%
and 57.5%, respectively). Half of the study participants in Group 3 worked, and
most of those who did not work were pensioners. Almost all of the respondents
with blindness (97.5%) worked as masseurs. In Indonesia, the department of social
aairs provides free masseur training programmes for people with blindness.
The vision-related quality of life of respondents with normal vision, corrected
visual impairment, uncorrected visual impairment and blindness, the results of
multivariate ANOVA and post-hoc analyses are presented in Table 1.
Table 1: Vision-related Quality of Life of People with Normal Vision (Group
1), Corrected Visual Impairment (Group 2), Uncorrected Visual Impairment
(Group 3) and Blindness (Group 4), the Results of Multivariate ANOVA and
Post-hoc Analyses of the 4 Groups
Vision-
related
Quality of
Life
Group 1
(G1)
Group 2
(G2)
Group 3
(G3)
Group 4
(G4)
Multivariate
ANOVA
Post-hoc
Analyses
Mean ±
SD
Mean ± SD Mean ± SD Mean ± SD F p
Total 946.84 ±
47.240
946.84 ±
47.240
781.29 ±
128.690
418.90 ±
89.468
282.469 <0.001 G1>G2**
G1>G3***
G1>G4***
G2>G3***
G2>G4***
G3>G4***
General
health
59.76 ±
15.690
55.610 ±
13.332
40.000 ±
21.780
44.375 ±
18.334
7,391 <0.001 G1>G3***
G1>G4***
G2>G3***
G2>G4**
General
vision
81.95 ±
6.008
77.561 ±
6.626
58.500 ±
12.310
15.000 ±
19.612
243,605 <0.001 G1>G3***
G1>G4***
G2>G3***
G2>G4***
G3>G4***
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Ocular pain 90.55 ±
14.344
82.317 ±
17.280
83.438 ±
21.067
75.300 ±
22.562
4,197 0,007 G1>G4***
Near vision
activities
99.02 ±
2.650
96.37 ±
6.495
64.782 ±
20.283
39.574 ±
11.757
204,248 <0.001 G1>G3***
G1>G4***
G2>G3***
G2>G4***
G3>G4***
Distance
vision
activities
98.63 ±
3.048
98.80 ±
3.487
69.995 ±
22.713
28.936 ±
8.427
285,248 <0.001 G1>G3***
G1>G4***
G2>G3***
G2>G4***
G3>G4***
Social
functioning
93.54 ±
8.571
88.83 ±
12.221
90.625 ±
12.894
55.000 ±
14.925
88,360 <0.001 G1>G4***
G2>G4***
G3>G4***
Mental
health
98.00 ±
5.996
86.37 ±
18.208
65.625 ±
14.572
67.506 ±
15.453
31,393 <0.001 G1>G2***
G1>G3***
G1>G4***
G2>G3***
G2>G4***
Dependency 97.95 ±
5.882
86.66 ±
15.106
64.787 ±
16.616
57.275 ±
17.314
56,033 <0.001 G1>G2***
G1>G3***
G1>G4***
G2>G3***
G2>G4***
G3>G4***
Role
diculties
89.98 ±
22.469
79.80 ±
31.610
68.750 ±
24.677
56.563 ±
19.812
10,615 <0.001 G1>G3***
G1>G4***
G2>G3***
G2>G4***
Colour
vision
99.39 ±
3.904
97.56 ±
15.617
98.750 ±
7.906
18.750 ±
30.356
208,119 <0.001 G1>G4***
G2>G4***
G3>G4***
Peripheral
vision
99.39 ±
3.904
96.95 ±
16.003
85.000 ±
24.547
5.000 ±
14.097
330,665 <0.001 G1>G3***
G1>G4***
G2>G3***
G2>G4***
** p<0.01
*** p<0.001
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Multivariate ANOVA that included age and sex as covariates, revealed a
signicant dierence in the NEI VFQ-25 total scores among the four groups of
respondents. Group 1 had the highest mean total vision-related quality of life
score and Group 4 had the lowest. Post- hoc analyses revealed there was no
signicant dierence between Group 1 and Group 2 respondents, but Group 1
and Group 2 respondents had signicantly higher scores than those in Group 3
and Group 4. The total vision-related quality of life score of Group 3 respondents
was signicantly higher than that of respondents in Group 4.
The mean vision-related quality of life scores of 11 subscales for the four groups
of respondents varied, although the mean scores of almost all subscale scores in
Group1 tended to be the highest, and those of Group 4 were likely to be the lowest.
In the general health subscale, post-hoc analysis showed that respondents in
Group 1 and Group 2 had signicantly higher general health scores than those
in Group 3 and Group 4. Respondents in Group 1 and Group 2 were reasonably
healthy, as the percentage with self-reported chronic diseases was below 20%.
Almost half of the respondents in Group 3 (47.5%) and 35% of those in Group 4
reported having a chronic health condition.
In the general vision subscale, there was no signicant dierence between Group
1 and Group 2. The correction of Group 2 respondents’ vision had a positive
impact on the vision-related quality of life general vision subscale. Respondents
in Group 1 and Group 2 had signicantly higher scores than respondents of
Group 3 and Group 4. Failure to make visual correction, leading to uncorrected
visual impairment or even blindness, resulted in lower vision-related quality of
life general vision subscale.
The results of near vision activities and distance vision activities subscales showed
that visual correction improved people’s ability to conduct near vision activities
like reading a book, cooking, sewing or xing things at home, as well as distance
vision activities such as reading street signs, watching movies, and going up and
down stairs at night.
In the social functioning subscale, the respondents in Groups 1, 2 and 3 had
signicantly higher scores than those in Group 4. Despite their visual limitations,
Group 2 and Group 3 respondents were able to understand other people’s
reactions during conversation or behave as expected when they were visiting
people or aending a party. People with blindness had more diculties in
fullling their social function which aected their vision-related quality of life.
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In the mental health subscale, Group 1 had a signicantly higher score than
the other three Groups. Group 2 respondents worried about their vision, felt
some frustration, had less control over what they did, and worried about being
embarrassed due to their visual impairment. Group 3 and Group 4 individuals
had bigger problems compared to Group 2 respondents, leading to lower vision-
related quality of life.
Post- hoc analysis showed that respondents in Group 1 and Group 2 had
signicantly higher vision-related quality of life role diculties subscale than
those in Group 3 and Group 4. Respondents in Group 3 and Group 4 thought
that they could not complete tasks on time and their performance was lower
because of their visual problem. Group 2 individuals did not think that their
visual impairment aected their performance.
In the dependency subscale, Group 1 had a signicantly higher score than the
other Groups. Respondents in Group 2 felt some dependency on what other
people said, and needed help from other people because of their visual problems.
Individuals in Group 3 and Group 4 had more diculties than those in Group 2.
Group 4 respondents even felt they were forced to stay at home most of the time
because of their blindness.
Group 1 and Group 2 individuals had signicantly higher peripheral vision
subscales than those in Group 3 and Group 4. People in Group 2 did not think
that they had signicant diculties in seeing things on the sides, while those in
Group 3 and Group 4 did.
There was no signicant dierence among respondents in Groups 1, 2 and 3 in
the colour vision subscale. The three groups had signicantly higher scores than
those in Group 4. Individuals in Group 2 and Group 3 did not have a signicant
problem in matching clothes, but those in Group 4 had a lot of problems in
performing this task.
DISCUSSION
People with normal vision had the highest total NEI VFQ-25 score and those with
blindness had the lowest, indicating that vision-related quality of life decreases
with the worsening of visual acuity. This is in accordance with other studies
conducted in other countries(Fleming et al, 2019; Tharaldsen et al, 2020; Yibekal
et al, 2020).
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Based on the NEI VFQ-25 subscale analysis, general health was found to be higher
in respondents with normal vision and corrected visual impairment than among
those with uncorrected visual impairment and blindness. This result suggests
that visual acuity may be an indicator of general health. Vision impairment has
been associated with chronic conditions in older adults(Court et al, 2014; Crews et
al, 2017). People with visual impairment are more likely to have health problems
compared to individuals with normal vision. Other researchers found cataract as
a predictor of mortality in people aged over 50 years (Zhu et al, 2016; Zhu et al,
2019). A recent review reported poor vision as a risk factor of falls in older adults
that may lead to fatality (Joseph et al, 2019).
Subscales of general vision, near vision activities, distance vision activities and
peripheral vision showed a signicant dierence, where respondents with normal
vision and corrected visual impairment had higher levels of functioning than
individuals with uncorrected visual impairment or blindness. Visual correction
may improve vision-related quality of life, while more severe visual impairment
may have a more adverse eect on vision-related quality of life. This nding is
consistent with other studies showing that best-corrected visual acuity can have
positive impact on vision-related quality of life(Råen et al, 2019).
There was no signicant dierence in the ocular pain subscale among respondents
with corrected vision, uncorrected vision and blindness. Ocular pain is commonly
associated with ocular surface disease found in most people with glaucoma. The
number of respondents with glaucoma in this study was low, and this might
explain the result(Baudouin et al, 2013; Tirpack et al, 2019).
This study suggests that visual acuity does not aect social functioning until
someone becomes blind. This nding is similar to studies that reported no
signicant dierence in social function between people with normal vision and
those with visual impairment(Dev et al, 2014; Heine et al, 2019). Respondents with
visual impairment could still carry out their social functions despite obstacles in
doing so. Respondents with blindness had many diculties in carrying out their
social functions, and experienced social isolation. Although most of the study
participants with blindness worked as masseurs, they waited for clients to visit
them because they had problems in moving around the city due to their visual
condition.
This study indicates that vision aects mental health. A study on older people
has associated self-reported visual impairment with depression(Frank et al,
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2019). Vision problems have been associated with worse psychosocial outcomes.
Visual impairment causes problems in doing everyday activities, i.e., reading
newspapers, recognising people. People with these problems have been reported
to have lower life satisfaction, increased depressive symptoms and decreased
positive aect(Hajek et al, 2020).
Dependency was dierent among all four groups; it increased with decreasing
visual acuity. This study shows that uncorrected visual impairment can lead to
role diculties, which is consistent with other researchers’ ndings that greater
visual impairment aects psychosocial parameters, including role diculty(Zhu
et al, 2015). Visual impairment forces the individual to take longer over completing
tasks, leading to lower performance.
Despite their corrected vision, respondents in Group 2 had lower quality of life
in the dependency subscale than those with normal vision. More than half of the
participants in Group 2 wore glasses to correct their visual impairment. Glasses
help people perform many activities, but those who wear them complain about
the inconvenience of having frequent eye check-ups and geing replacements to
keep good vision(Kandel et al, 2017). Without glasses, they need help from others
to accomplish tasks. Visual impairment decreases one’s independence in doing
activities of daily living, and increases dependence on other people. Individuals
with uncorrected visual impairment or blindness have more dependency on
others in their daily lives.
This study suggests that neither corrected nor uncorrected visual impairment
creates a signicant problem in colour vision, but blindness does. This nding is
consistent with other researchers who reported a similar result(Zhu et al, 2015).
Limitations
This study assessed vision-related quality of life based on the levels of vision, and
did not analyse by specic diagnosis.
Comparison between the Groups may have been hampered by the diering
sources of research participants. Participants in Groups 1 and 4 were recruited
from the community, while participants in Groups 2 and 3 were clients from a
hospital eye clinic.
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CONCLUSION
It can be concluded that there are signicant dierences in vision-related quality of
life related to people with normal vision, corrected visual impairment, uncorrected
visual impairment and blindness. Visual impairment has a detrimental impact
on a person’s vision-related quality of life. However, it has dierential impacts
on dierent elements of vision-related quality of life. There are no signicant
dierences between people with normal vision and corrected visual impairment
in most subscales, suggesting that visual correction can improve vision-related
quality of life, and thereby highlighting the importance of visual acuity correction.
ACKNOWLEDGEMENT
The authors would like to thank all those who participated in this research.
No nancial support was received for this research.
The researchers report no conicts of interest.
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