Clinical Ophthalmology Dovepress open access to scientific and medical research Open Access Full Text Article ORIGINAL RESEARCH Exploring Vision-Related Quality of Life: A Qualitative Study Comparing Patients’ Experience of Cataract Surgery with a Standard Monofocal IOL and an Enhanced Monofocal IOL Sergi Blancafort Alias 1 , Zoraida Del Campo Carrasco 2 , Ignacio Salvador-Miras 2 , Sabina Luna Mariné 2 , María José Gómez Prieto 2 , Francesca Liñán Martín 2 , Antoni Salvà Casanovas 1 1 Fundació Salut i Envelliment (Health and Ageing Foundation), Universitat Autònoma de Barcelona (UAB), Barcelona, 08041, Spain; 2Service of Ophthalmology, Hospital de Sant Pau, Barcelona, 08025, Spain Correspondence: Sergi Blancafort Alias, Fundació Salut i Envelliment (Health and Ageing Foundation), Universitat Autònoma de Barcelona (UAB), Sant Antoni Maria Claret, 171, Barcelona, 08041, Spain, Tel +34 93 433 50 30, Email sergi.blancafort@uab.cat Purpose: To explore quality of life related with intermediate vision of patients before and after cataract surgery, and to make patients’ experience available for the design of future scales that assess visual function related with intermediate distance. Patients and Methods: A qualitative research methodology based on thematic content analysis was used to explore vision-related quality of life based on the experiences of patients with cataract. Patients were recruited at the Service of Ophthalmology of the Hospital de Sant Pau (Barcelona, Spain). Data were collected through nineteen semi-structured interviews conducted with patients diagnosed with cataract and implanted with a standard aspheric monofocal intraocular lens (IOL) (Tecnis® ZA9003) (n = 6), an enhanced monofocal IOL (Tecnis® Eyhance ICB000) (n = 6), and patients from the waiting list (n = 7). The data analysis consisted in coding, aggregation, and theme development of the transcribed audios. Results: Patients on waiting lists reported difficulty and insecurity in performing daily and meaningful tasks related to near visual ranges (eg: threading a needle, reading price tags), intermediate (eg: using a computer or dialling numbers on a smartphone), and distant (eg: recognizing faces, walking on uneven surfaces). Patients after surgery with the standard IOL reported improvement in performing activities mainly in the distant visual range, but also the need for a better communication with clinical staff to adjust their own expectations on the results of the surgery. Finally, patients implanted with the enhanced IOL reported satisfaction and improved visual function in performing daily activities, especially those related to the intermediate visual range. Conclusion: Our exploratory study found that patients after cataract surgery with the enhanced IOL reported a better performance in activities that require the intermediate vision. These results will inform the development of scales to assess vision-related quality of life in the intermediate visual range prioritizing outcomes according to patients’ daily and meaningful activities. Keywords: quality of life, cataract, qualitative research, intraocular lenses Introduction Cataract is among the most common causes of visual impairment in older people, affecting more than 90% of those aged 65 and over.1 Visual impairment has an impact on person’s ability to perform tasks safely and easily in different functional domains, including ambulation, driving, household management, work performance, financial and legal responsibilities, and recreation and leisure activities.2 Visual impairment in older adults is also associated with reduced participation,3 mobility functions,4 falls risk5 and to a fear of falling, which restrict their physical activities and put them at risk for social isolation and disability6 and can lead to functional decline, depression, increased falls risk, and reduced quality of life.5 Moreover, visually impaired people generally have a higher prevalence of anxiety disorders and Clinical Ophthalmology 2022:16 1641–1652 1641 Received: 31 January 2022 © 2022 Blancafort Alias et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress. Accepted: 29 April 2022 com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly Published: 27 May 2022 attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Blancafort Alias et al Dovepress depression compared with people with good vision.7,8 Hence, visual impairment has an impact on all aspects of daily life9 and threatens the well-being of the individual.10 Cataract surgery has been shown to be cost-effective and to report consistent benefits in reducing disability, limitation in activities, anxiety, depression, risk of falls and fractures,11–17 being phacoemulsification the preferred surgical technique in the developed world and tertiary centers in developing countries to remove cataract.18–21 Several types of new intraocular lenses (IOL) have been introduced in surgical procedures during last years and reported to influence patients’ opinions about their vision after cataract extraction.22 A few studies have shown that an enhanced monofocal IOL provides, compared to other standard monofocal IOL, similar visual acuity at near and distant range and better performance at the intermediate distance range (50–100 cm).23–27 Intermediate distance range covers a zone of activities including computer work, cooking, shopping, engaging in conversation, eating, controlling the car dashboard, or organizing a desk. Hence, it may be a reasonable option for those more dependent on intermediate vision in daily activities.28 From the patient’s viewpoint, cataract and cataract surgery can influence many quality-of-life aspects affected by poor visual acuity, which may include ocular symptoms (eg, glare and halos), limitations to activities of daily living and convenience (freedom from spectacles).29 Vision-related quality of life is a growing topic of interest in the literature. It is related with patients’ concerns about coping with everyday life, incapacity to carry out ability preferred activities, and psychological distress including fear, lack of safety, frustration, annoyance, depression, embarrassment, and loneliness.30 However, vision-related quality of life in patients with cataract has been mostly assessed using ophthalmic instruments originally developed for other eye diseases or non-disease specific patient-reported outcome instruments, and hence less sensitive to change.31,32 Furthermore, few questionnaires measuring patient-reported outcomes related to visual function have been developed for cataract surgery,33,34 and no specific scales have been identified to assess visual function in the intermediate distance range. The aim of this study was to explore vision-related quality of life of patients before and after cataract surgery with different types of IOL and to highlight relevant issues for the future development of scales that assess visual function in the intermediate visual range. Materials and Methods The qualitative theoretical framework used in this study was phenomenology, which aims to describe the essence of a phenomenon from the perspective of those who have experienced it.35 A convenience sampling technique was used to recruit 19 patients diagnosed with cataract through the service of ophthalmology at Hospital de Sant Pau (Barcelona, Spain). Sample size determination was guided by the criterion of saturation and informational redundancy, which means that no new data is elicited by sampling more units. Participants were distributed into one of these three study groups: Patients implanted with a standard aspheric monofocal IOL (Tecnis® ZA9003) (Group 1), patients implanted with an enhanced monofocal IOL (Tecnis® Eyhance ICB000) (Group 2), and patients from the waiting list (Group 3). The difference between the two lenses is that the model of the standard IOL is exclusively monofocal, while the enhanced IOL is monofocal with an improved intermediate function. The latter features a smooth continuous power change from the center towards the lens periphery. This feature seems to increase the depth of focus, thus mitigating the effects of presbyopia and delivering sharp vision at different distances. Both models have a modified anterior surface with a sphericity of −0.27 μm across their entire optic zone of 6 mm. They also have a 360 degrees continuous posterior squared margin. Their Abbe number is 55 and refractive index is 1.47. Inclusion criteria: Patients had to be aged 65 or over, to be diagnosed with cataract, and to be emmetrope post- operatively (Sphere ± 0,5D; CyL ≤ 0,75D) with binocular visual acuity of at least 1.0 measured on the Snellen scale (groups 1 and 2) or with binocular visual acuity of 0.5 (6/12) (minimum eyesight standard for driving) measured on the Snellen scale (group 3). To avoid recall bias, patients did not know the type of lens they had been implanted. Face-to-face interviews were conducted between June and October of 2020. Due to the outbreak of the second wave of the COVID-19 pandemic in Spain (November 2020), the research team decided to carry out phone interviews instead of face-to-face interviews, until data saturation was reached. Moreover, three health professionals (two ophthalmologists and one optometrist) from the Service of Ophthalmology of the Hospital de Sant Pau were interviewed for triangulation purposes. 1642 https://doi.org/10.2147/OPTH.S358386 Clinical Ophthalmology 2022:16 DovePress Powered by TCPDF (www.tcpdf.org) Dovepress Blancafort Alias et al A semi-structured questionnaire with open-ended questions was developed ad hoc and used for the interviews. The questionnaire explored aspects related to the difficulty perceived by participants in performing tasks at different visual ranges before and after surgery, and its impact on several aspects of their vision-related quality of life. Adjustments to the questionnaire were made according to the data collection method (face-to-face or phone interview) and to previous experience and information participants had provided. All interviews were carried out by a researcher with a background in sociology of health who was not known to the participants before the beginning of the study. Face-to-face interviews were conducted in consultation rooms located at the Service of Ophthalmology at the Hospital de Sant Pau with all measures to prevent the transmission of COVID-19 (wearing masks, physical distancing, hydroalcoholic gel and ventilation). With respect to phone interviews, they were previously scheduled so that patients could feel comfortable and have enough time to attend the call. All interviews were digitally recorded with permission from participants and transcribed onto a Microsoft Word® file. Data collected were listed, coded, and categorized by visual range adapting the framework proposed by Atkinson et al.36 Data processing occurred as an iterative process, so analysis started before data collection was completed. The study was complied with the Declaration of Helsinki and approved by the Ethics Committee of the Autonomous University of Barcelona. Participants received oral and written information about the study and signed the informed consent, which included publication of anonymised data. Participation in the study was volunteer, and participants did not receive any economic compensation. Results The characteristics of participants are presented in Table 1. The age of participants ranged from 63 to 85 years old. Almost twice as many participants were women (63.16%). About half of participants had completed secondary studies (42.10%), a little more than a fourth had completed higher studies (26.31%) and a little less than a third (31.58%) had completed only primary studies or had not completed any studies at all. Only four participants (21.05%) were born in the same city where they currently live (Barcelona). The majority of them were married (68%) with only one participant living alone (5.26%). Performance of Daily Tasks Before Surgery Transcripts were used to create lists of vision-dependent tasks organized in continuous visual ranges. Tables 2–4 show tasks reported by patients as difficult to perform in the near, intermediate, and distant visual range before cataract surgery. Table 1 Characteristics of Participants by Group Total Waiting List Standard IOL Enhanced IOL (n = 19) (n = 7) (n = 6) (n = 6) Age, in years, mean (standard deviation) 74.9 (6.82) 73.9 (6.2) 75.7 (8.4) 82.4 (6.9) Gender Women, n (%) 12 (63.16) 6 (85.71) 4 (66.67) 2 (33.33) Men, n (%) 7 (36.84) 1 (14.29) 2 (33.33) 4 (66.67) Education level Without or only primary studies, n (%) 6 (31.58) 3 (42.86) 1 (16.67) 2 (33.33) Secondary studies, n (%) 8 (42.10) 3 (42.86) 1 (16.67) 4 (66.67) Higher studies, n (%) 5 (26.31) 1 (14.28) 4 (66.66) 0 (0.00) Born in the same city where currently living, n (%) 4 (21.05) 1 (14.28) 2 (33.33) 1 (16.67) Marital status, n (%) Married, n (%) 13 (68.42) 5 (71.44) 2 (33.33) 6 (100.00) Separated or divorced, n (%) 3 (15.79) 1 (14.28) 2 (33.33) 0 (0.00) Widow, n (%) 2 (10.53) 1 (14.28) 1 (16.67) 0 (0.00) Religious, n (%) 1 (5.26) 0 (0.00) 1 (16.67) 0 (0.00) Living alone, n (%) 1 (5.26) 1 (14.28) 0 (0.00) 0 (0.00) Note: n=number of participants. Clinical Ophthalmology 2022:16 https://doi.org/10.2147/OPTH.S358386 1643 DovePress Powered by TCPDF (www.tcpdf.org) Blancafort Alias et al Dovepress Table 2 Performance of Tasks in the Near Visual Range Before the Surgery Task Verbatim Participant Threading a needle “If I start sewing something I like, threading a needle is a mess. Woman, 68, waiting list, I mean … it’s an uphill climb to me. That’s probably what I find secondary studies most difficult.” Taking fine measurements “When I had to take fine measures … or connect cables” Man, 71, enhanced IOL, secondary studies Use tools (screwdriver, hammer, pliers, “If a radio or a watch is ruined … o some mechanical staff … Man, 75, enhanced IOL, etc) to fix and/or adjust small objects I have fun with it. But I need more light, because when there is not secondary studies much light you don’t see it well” “Screws … it’s a handicap. I created strategies like picking up Man, 68, enhanced IOL, a magnifying glass. But to pick up a screw and look what kind of secondary studies screwdriver you need … it was difficult” Do activities related to personal care “What I noticed more is that I needed a lot of light from the very Man, 75, enhanced IOL, (shaving, cutting nails, making up) near distance, and very powerful, to do some things … shaving, for secondary studies example” Read medication and/or nutritional “I go shopping with him (husband). The prices … he tells me Woman, 85, waiting list, without labels, price tags and/or expiration dates because I can’t see them well.” studies on products “The most difficult thing is when I go shopping. Labels that are Woman, 68, waiting list, sometimes interesting to look at, sugar … this is the most difficult. secondary studies More than reading a book or looking at the mobile phone.” Enjoy reading books, journals and/or “I wish I could read better clearer. Now all the letters come Woman, 85, waiting list, without newspapers together.” studies “When you have to read 500 or 1.000 pages … after two hours Man, 68, enhanced IOL, with your eyes fixed in the book … it was difficult, much more secondary studies than before”. “I just wanted to read after the surgery. Not being able to read … it has been very hard for me (starts crying). … I have not been able to read well … however I have been able to do some small crafts, with some difficulty, but I have to do something in my life because I am an active woman” “Reading as I read before, because I really liked reading, both Woman, 72, waiting list, books and magazines, watch television, or sew sometimes, too … secondary studies I can’t do it because of the eyes.” “Even if it is a little, read a little, because immediately my eyes become like they were in tears and cloudy. When I watch the TV, I open and close my eyes again and again, because I need to do it to see, I get an itch … As much in the right eye, which is the one I have got sick, as in the left. Now the left is the one I feel more tired.” Some examples of daily activities related to near vision included threading a needle and do-it-yourself tasks, while others imply strong limitations when shopping in a supermarket (see the price tags of products, read the expiration dates on nutritional labels). Reading also emerged as an important activity for patients, which was limited by cataract, causing feelings of disappointment, frustration, and sadness. Regarding the intermediate visual range, using the computer and watching TV were two of the most frequently mentioned activities. Specifically, they named problems to see the faces 1644 https://doi.org/10.2147/OPTH.S358386 Clinical Ophthalmology 2022:16 DovePress Powered by TCPDF (www.tcpdf.org) Dovepress Blancafort Alias et al Table 3 Performance of Tasks in the Intermediate Visual Range Before the Surgery Task Verbatim Participant Use a standard size computer or laptop (to see “Mid-distance, especially if you are working with Woman, 69, waiting list, images, watch videos, read/write e-mails) a computer … if you cannot see well then it’s secondary studies a problem … or you go shopping and you cannot see the prices … and that’s important. Up close, reading, for example, is very important … but mid-distance is very important, too … ” Enjoy hobbies and games within an intermediate “When I start sewing, or reading, I put on my glasses. Woman, 85, waiting list, distance range (sewing, cross stitch pattern, Otherwise, I couldn’t.” without studies gardening, playing cards, painting, etc) “Sewing … I can’t do it right.” “Although I see well up close, it’s hard for me to do cross Woman, 69, waiting list, stitch pattern, and I’ve had to leave it … I couldn’t.” secondary studies Feel steady and confident when falling on uneven “I don’t feel safe when I’m on the street. If there’s Woman, 68, waiting list, ground, walk around without fear of falling, climb or a step … I’m careful about that.” secondary studies descend stairs “I had headache on the street before, because I wasn’t Woman, 71, enhanced IOL, safe” primary studies “There are several things that you have to pay attention to Woman, 68, waiting list, much more than before. For example, walking down the secondary studies street is what I find most dangerous, if there are slopes … ” “Then when you go out … well I am very afraid of falling Woman, 69, waiting list, because you do not see well … I always look at the secondary studies ground, because if there is a slope you do not see it …” “Changes on the surface of the ground … you don’t Man, 68, enhanced IOL, perceive them with the same sharpness as before” secondary studies “If I had better vision, I would go safer, I find myself Woman, 72, waiting list, insecure. What happens to me is that the place where secondary studies I live, I have got the shop in front of my house, and this is what is useful for me. Going to the first supermarket … I dare more than going to the others, which are two streets further.” Recognize people you know across the room “That in the intermediate distance … it was basic … Man, 68, enhanced IOL, perceive that someone’s coming … and not have to wait secondary studies at the last moment to greet. And the paddle, the ball … I couldn’t reach it, and I had never arrived late in my life” “When you saw some in the distance, but until he moved Man, 68, enhanced IOL, closer like this … I could not see his face sharply” secondary studies See facial expressions of friends or loved ones “And it’s the same thing with the faces, sometimes I see Woman, 69, waiting list, a person coming and I know that’s my daughter by the way secondary studies she moves, but until she’s close I can’t see her face well … it’s difficult for me to distinguish the faces.” (Continued) Clinical Ophthalmology 2022:16 https://doi.org/10.2147/OPTH.S358386 1645 DovePress Powered by TCPDF (www.tcpdf.org) Blancafort Alias et al Dovepress Table 3 (Continued). Task Verbatim Participant Read subtitles on the TV “I can still read, but to watch TV, read subtitles … Woman, 68, waiting list, neither.” secondary studies “I used to wear glasses to sew, and that’s all. But it arrived Woman, 71, enhanced IOL, a day that I started to see the TV blurred” primary studies “You’re watching TV, you don’t see the faces well, you Woman, 69, waiting list, can’t read the subtitles, and that makes you nervous” secondary studies Table 4 Performance of Tasks in the Distant Visual Range Before the Surgery Task Verbatim Participant See traffic lights, signals, lines of the road and/ “When driving, at night, the lines (of the road) … you do not Man, 68, enhanced IOL, or intersections when driving or being inside perceive with the same acuity, or if somebody was coming with the secondary studies a car light a little bit higher … the blinding was bigger than before … And this last summer, one of the days we went out, it was hazy in the road … until it cleared up, it was an agony for me … because my eyes could not …. and you reduce the speed so much” Drive and/or feel safely in a car (at night, with “And when you’re in the car, as you don’t see well, you have the Woman, 69, waiting list, oncoming lights or bright sunlight, etc) sensation that the driver sees as bad as you, and this is something secondary studies that makes me anxious, this is what worries me the most.” “Until now, I used to wear glasses for the distant visual range, for Man, 68, enhanced IOL, example when driving. But lately, when I put on my glasses, they secondary studies were not very useful, because the cataract prevented me to have a good visual acuity … you put your glasses and you did not achieve the same outcome as before” Participating in outdoor activities without “To do some sports, paddle, specifically. Outdoor, I had to start Man, 68, enhanced IOL, being handicapped by glare wearing glasses” secondary studies and read the subtitles on the screen. A second group of tasks that patients were unable to enjoy before the surgery included handcraft activities (eg, sewing and cross-stitch pattern). Thirdly, feelings of fear, insecurity, or even physical symptoms (eg, headache) emerged when patients talk about their difficulties to walk on uneven ground or to climb and/or descend steps, which clearly limit the possibility of going out from home. Finally, patients also highlighted the difficult of recognizing people at a certain approaching distance as well as facial expressions, which is something that obviously can affect social relationships. With respect to distant range, several examples were given related to the lack of safety when driving, either at night or with adverse atmospheric conditions. Other patients expressed feelings of anxiety when travelling inside a car before cataract surgery. One last example pointed to the difficulty of following small rapid balls, which means the impossibility to enjoy some sports. Impact of Cataract Surgery on the Vision-Related Quality of Life Table 5 shows changes in the performance of vision-dependent tasks and vision-related quality of life before and after surgery. With respect to near and distant vision, improvements in the performance of tasks were found in patients who were implanted with the standard IOL as well as those implanted with the enhanced IOL. Examples given by participants referred to the possibility of seeing their own wrinkles for the first time, reading price tags, and threading a needle. They expressed their satisfaction to see things clearer, which implies that they were able to drive safer and to enjoy sightseeing. As for the intermediate visual range, only patients implanted with the enhanced IOL reported improvements in the 1646 https://doi.org/10.2147/OPTH.S358386 Clinical Ophthalmology 2022:16 DovePress Powered by TCPDF (www.tcpdf.org) Dovepress Blancafort Alias et al Table 5 Changes in the Performance of Vision-Dependent Tasks and Vision-Related Quality of Life Before and After Surgery Visual Range Type of Lens Verbatim Participant Near Standard IOL “When I went surgery for the left eye, and I looked myself in the mirror. Woman, 78, without God! How many wrinkles I have … and what a wrinkled face I’ve got …, studies and I didn’t see it before.” Enhanced IOL “And also in the nearby, because if I had to thread a needle … very bad, Woman, 84, primary very bad … Now I don’t see well to do this, because my vision is not studies enough, but I can still thread with light, and I couldn’t before” Near, Enhanced IOL “Now, if I go to the supermarket, I see much better the price tags of Man, 71, secondary intermediate products. The subtitles of the TV, I also see them better” studies Intermediate Enhanced IOL “I have noticed a change, most of all in the intermediate distance. In the Man, 68, secondary nearby … I still need glasses, and I do not care about wearing them for studies the long-distance vision, because they are very specific activities. But I am happy to lead a normal life, without losing time trying to fix the glance o looking for your glasses … at the end you have glasses for the near, glasses for the long … and sometimes they do not adjust” “Uneven surfaces … I see them fine now, maybe I had to gaze to them Man, 71, secondary before. If I had to climb or descend stairs, I had to pay much more studies attention” “I was not safe (on the street), because sometimes I was walking” Woman, 84, primary studies “When I went surgery I told the doctor. Wow! You are very handsome! Woman, 71, primary I could not well the faces before” studies Enhanced IOL “Now I cannot read, nor see the cell phone, nor sewing … because Woman, 71, primary I cannot see in the nearby. But now I see well I see the buses when they studies are coming, a sign, anything like this, o the faces of people, because before … I saw a person, but I could not identify him. Now I can” “For example, when reading digital media. It’s very unusual for me to Man, 68, secondary look for glasses. When I was in the underground, I had to stop in front studies of the panel of the stations to check if I had to go to the left or to the right. But it was not looking sideways … as I have done all my life … I had to stop, try to locate the station … I mean, paying much more attention, because the vision is not the same. And now it has improved a lot.” Enhanced monofocal “I go dancing. You enter and you see people, but you do not see the Woman, 71, primary IOL faces. I saw the faces before, and also now (after the surgery). It’s very studies important to enter somewhere and see the faces. Without wearing glasses. I do not like wearing glasses, since I was a child, even if they suits me well … I do not want glasses. I prefer not to have to wear them” “The TV … I see it fine. It was not terrible before, but clarity and Woman, 84, primary that … I didn’t see as much. Now much clearer, yes, much clearer.” studies “I don’t need glasses to watch TV now. I see subtitles perfectly” Woman, 71, primary studies Intermediate, Enhanced IOL “If I could have chosen, I had chosen what I’ve been done. Wearing Woman, 71, primary distant glasses only for nearest things” studies (Continued) Clinical Ophthalmology 2022:16 https://doi.org/10.2147/OPTH.S358386 1647 DovePress Powered by TCPDF (www.tcpdf.org) Blancafort Alias et al Dovepress Table 5 (Continued). Visual Range Type of Lens Verbatim Participant Distant Standard IOL “After surgery, the vision has improved at the long distance. The Woman, 63, higher studies difference is that I see clearer now, but not cleaner.” “I can see the lines in the road now, well outlined” Man, higher studies “I can sit down and enjoy sightseeing now” Woman, 68, higher studies “See the streets, clearly, the people, the trees, all these things have Man, 84, secondary improved” studies Enhanced IOL “Now, for the distant vision … I see better than before. I see the same Man, 71, secondary with or without glasses. Before the surgery, they told me that I would studies not need glasses for the distant vision” “I notice more light. And at the long distance, I see better than before” Man, 75, secondary studies “To drive … I see much better than before. Many times I put my glasses Man, 71, secondary like this (points to his forehead) because I don’t need. Before the studies surgery I felt better wearing glasses” “Now I see much more clearer when I drive. I noticed the difference. Man, 68, secondary Traffic signs … perfect” studies Overall vision- Enhanced IOL “I had to turn to my glasses to read anything before, to read very Man, 68, secondary related quality normal things. And now I don’t need glasses. My quality of life had studies of life worsen compared to before the cataracts. And now I’ve recovered it”. “I had to search how to accommodate my vision all the time … Man, 68, secondary Everybody is very satisfied now, because I’ve recovered part of the studies quality of life that I had lost”. “I do not have any problem to see the cell phone. To watch TV, better, Man, 75, secondary you notice it so much, because I saw double the subtitles, and now I see studies the perfectly without glasses. With no doubt, for the near, intermediate distance, I see perfectly. At the long distance … I see an antenna at the top of the building in front of my house, and I see it well outlined. Now I see it as well as more than a year before … I mean … fine.” “We have to remove the cataract, or whatever, so we can see and have Woman, 71, primary a quality of life that if you could reach it … you can help other people studies with any problem they have, for example, someone who stops you on the street and tells you … Hey, cannot you look this for me? I cannot see well … ” “A whole world … I couldn’t imagine I see so well again … now that I’ve Woman, 71, primary gone on surgery … I don’t remember I could see so fine … you can’t studies explain it in words” “For the daily life of a normal person … it has improved a lot. To read. Man, 75, secondary I saw double before, and I see perfectly now” studies performance of some tasks. Several examples were referred to feel safer walking on the street due to the possibility of seeing well uneven surfaces or steps. A few patients related that they had enjoyed watching the TV again because they could read the subtitles and see images. Nevertheless, it was easier for them to use the public transport because they could clearly read the numbers of the buses or the names of the stations, while others expressed their joy due to the 1648 https://doi.org/10.2147/OPTH.S358386 Clinical Ophthalmology 2022:16 DovePress Powered by TCPDF (www.tcpdf.org) Dovepress Blancafort Alias et al possibility of recognizing faces, which was considered very important for social interaction. Additionally, several participants mentioned that they had gained additional comfort because they only needed to wear glasses for few tasks at a near distance. Finally, some patients implanted with the enhanced IOL made comments explicitly referring to the quality of life they have recovered after the surgery, because they did not need to accommodate the vision or wear glasses all the time, they could see clearly along different visual ranges or even help other people with vision limitations. Discussion This study was aimed to explore intermediate vision-related quality of life of patients before and after cataract surgery with a standard IOL and an enhanced IOL. Particularly, we identified limitations to perform vision-dependent tasks in the near, intermediate, and distant visual ranges, and assessed the degree of difficulty and importance of activities of daily living, before and after the surgery with both IOL. Furthermore, we tried to establish vision-related quality of life relevant issues for the future development of patient-reported outcomes measures of visual function, and to provide evidence of content validity for the design of future scales that assess visual tasks or functions occurring in the intermediate visual range. We used phenomenology as a valid qualitative theoretical framework to carry out the study, which has been widely used in the field of ophthalmology to explore patients’ quality of life.37–39 Data were collected through 19 semi-structured interviews conducted with patients in the waiting list for cataract surgery, implanted with a standard IOL and an enhanced IOL. Our findings showed that patients from waiting list reported difficulty in performing daily tasks related with near, intermediate, and distant visual ranges. Patients after surgery with either standard or enhanced IOL reported improvement in performing activities in the near and distant visual ranges, and the need for a better communication with clinical staff to adjust own expectations. However, only patients implanted with the enhanced IOL reported major satisfaction and improved visual function in performing daily living activities related to the intermediate and extended-intermediate visual range. Several studies have reported the same visual acuity at near and distant range and better outcomes at intermediate distance range.23–27 Visual function in patients affected by cataract has been traditionally assessed using visual acuity instruments. However, these measures do not reflect the major effects that cataract have in vision-related quality of life, caused mostly by difficulty in performing daily and meaningful tasks.40 Some researchers have evidenced how self-reported measures of vision-related quality of life can be helpful to assess the subjective wellbeing and visual disability of patients when they perform common activities in daily life41 and hence, several questionnaires examining vision- related quality of life have been developed with research purposes.42,43 Two of the questionnaires mostly used with this aim are the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25)44 designed to assess quality of life in patients with visual problems, and the Visual Function Index-14 (VF-14) designed to measure functional impairment on patients due to cataract and largely used in the Spanish population.45 However, several researchers46,47 have reported problems with the utilization of both instruments, such as measurement redundancies and measurement voids, suggesting a low ability to differentiate among participants with higher levels of visual function, and concluding that neither the NEI VFQ-25 nor VF-14 is optimal for the assessment of vision-related quality of life in patients with cataract surgery.29 During last years, researchers have also focused their efforts on the development of cataract patient-reported outcome measures with enough characteristics in terms of brevity, precision, and responsiveness to be used in clinical practice.48 Among them, the Catquest-9SF49,50 and the most recent CAT- PROM34 have shown to be short, psychometrically robust instruments. Both have been validated in English-speaking contexts and Catquest-9F has also been validated in other languages including Spanish.51,52 The use of qualitative research to establish the basis of task-based content for patient-reported outcomes of visual function have been explored previously by other researchers36 who identified several gaps in task content and distance-specific constructs associated with visual function, including the lack of scales to assess visual tasks for the intermediate visual range, as well as to assess the use of technological devices, and the fact that there were only found two measures to assess ambulatory accident risks. Clinical Ophthalmology 2022:16 https://doi.org/10.2147/OPTH.S358386 1649 DovePress Powered by TCPDF (www.tcpdf.org) Blancafort Alias et al Dovepress Strengths and Limitations of the Study Our study has several limitations. First, the COVID-19 pandemic has dramatically affected the development of the study. Recruitment and availability of patients was compromised by successive outbreaks, and the final round of interviews had to be completed by phone. This is an important point to consider when it comes to interpreting the results. Secondly, the relevance of tasks and activities highlighted by patients may be considered with caution due to the diversity of profiles, the specific pandemic context, and the fact that the sample was limited, and thus socio- demographic characteristics of the participants (sex, age, educational level) may influence the kind of tasks or activities reported. For example, six of the seven patients in the waiting list group included in the study were women, and due to the generational context, examples of activities mentioned may be subjected to bias. Otherwise, the educational level achieved by participants may also influence the type of activities performed. Previous research has suggested the use of Ecological Event Monitoring methodology to identify routine tasks, which may be affected by poor vision, as well as keeping a daily event register of specific difficulties.53 Data collection and analysis were performed along six months (June 16th, 2020-December 28th, 2020) for several reasons. First, the epidemiological context due to the COVID-19 pandemic conditioned the possibility of doing interviews with patients. Second, fear of infection and workload of the clinical staff influenced the recruitment. Third, interviews with patients from Group 2 were conditioned to the availability of enhanced IOL. However, we believe that the results of our qualitative research provide rich and detailed information about the importance and meaningfulness of daily tasks influencing several domains of life. In particular, we point to the tasks performed in the intermediate visual range as potential items to consider when designing instruments to improve vision-related quality of life. Moreover, our findings provide support for the inclusion of technology tasks and task safety content in future measures of cataract patient-reported outcomes. Further research is required to examine the relationships between the visual distances required for task performance and their associations with established clinical measures of visual acuity and vision-related quality of life. Conclusion Our exploratory qualitative study found that patients after cataract surgery with an enhanced IOL reported a better performance of activities that require the intermediate visual range. Further research aimed to develop scales assessing vision-related quality of life in these visual ranges should prioritize outcomes according to patients’ daily and meaningful activities. In particular, our findings provide support for the inclusion of technology tasks and task safety content in future measures of cataract patient-reported outcomes. Acknowledgments This study has been funded by Johnson and Johnson Vision Surgical through an Independent Investigator Study (IIS) Research Grant. Johnson & Johnson Vision Surgical provided 16 Tecnis® Eyhance ICB000 Intraocular Lens free of charge for the aims of the study. The authors would like to thank the patients who participated in the study for their valuable contribution and their time. A communication (poster) of this work was presented at the congress of the European Society of Cataract and Refractive Surgery (ESCRS). Disclosure Dr Ignacio Salvador-Miras reports personal fees from Johnson and Johnson Vision, outside the submitted work; Dr. Sergi Blancafort Alias and Dr Antoni Salvà Casanovas report grants from Johnson and Johnson Vision Surgical, during the conduct of the study. The authors declare no other conflicts of interest in this work. References 1. GBD 2019 Blindness and Vision Impairment Collaborators; Vision Loss Expert Group of the Global Burden of Disease Study. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: the right to sight: an analysis for the Global Burden of Disease Study [published correction appears in Lancet Glob Health. 2021 Apr;9(4):e408]. Lancet Glob Health. 2021;9(2):e144–e160. doi:10.1016/S2214-109X(20)30489-7. 1650 https://doi.org/10.2147/OPTH.S358386 Clinical Ophthalmology 2022:16 DovePress Powered by TCPDF (www.tcpdf.org) Dovepress Blancafort Alias et al 2. World Health Organization. Blindness and Vision impairment; October 14, 2021. Available from: http://www.who.int/news-room/fact-sheets/detail/ blindness-and-visual-impairment. Accessed May 10, 2022. 3. Shah K, Frank CR, Ehrlich JR. The association between vision impairment and social participation in community-dwelling adults: a systematic review. Eye. 2020;34(2):290–298. doi:10.1038/s41433-019-0712-8 4. Miyata K, Yoshikawa T, Harano A, Ueda T, Ogata N. Effects of visual impairment on mobility functions in elderly: results of Fujiwara-kyo Eye Study. PLoS One. 2021;16(1):e0244997. doi:10.1371/journal.pone.0244997 5. White UE, Black AA, Wood JM, Delbaere K. Fear of falling in vision impairment. Optom Vis Sci. 2015;92(6):730–735. doi:10.1097/ OPX.0000000000000596 6. Wang MY, Rousseau J, Boisjoly H, et al. Activity limitation due to a fear of falling in older adults with eye disease. Invest Ophthalmol Vis Sci. 2012;53(13):7967–7972. doi:10.1167/iovs.12-10701 7. Evans JR, Fletcher AE, Wormald RP. Depression and anxiety in visually impaired older people. Ophthalmology. 2007;114(2):283–288. doi:10.1016/j.ophtha.2006.10.006 8. Binder KW, Wrzesińska MA, Kocur J. Anxiety in persons with visual impairment. Psychiatr Pol. 2020;54(2):279–288. English, Polish. doi:10.12740/PP/OnlineFirst/85408 9. Stevelink SA, Malcolm EM, Fear NT. Visual impairment, coping strategies and impact on daily life: a qualitative study among working-age UK ex-service personnel. BMC Public Health. 2015;15(1):1118. doi:10.1186/s12889-015-2455-1 10. Weber JA, Wong KB. Older adults coping with vision loss. Home Health Care Serv Q. 2010;29(3):105–119. doi:10.1080/01621424.2010.511505 11. Bourne RRA, Flaxman SR, Braithwaite T, et al. Magnitude, temporal trends, and projections of the global prevalence of blindness and distance and near vision impairment: a systematic review and meta-analysis. Lancet Glob Health. 2017;5(9):e888–e89. doi:10.1016/S2214-109X(17)30293-0 12. IAPB Vision Atlas. Number of people affected by vision loss; 2020. Available from: http://atlas.iapb.org/global-burden-vision-impairment/gbvi- global-cause-estimates. Accessed May 10, 2022. 13. Kupfer C. The National Eye Institute’s low vision education program: improving quality of life. Ophthalmology. 2020;107(2):229–230. doi:10.1016/S0161-6420(99)00094-9 14. Universal eye health: a global action plan 2014–2019. Geneva: World Health Organization; 2013. Available from: http://www.who.int/blindness/ actionplan/en/., Accessed 27 July 2017. 15. Vela C, Samson E, Zunzunegui MV, Haddad S, Aubin MJ, Freeman EE. Eye care utilization by older adults in low, middle, and high income countries. BMC Ophthalmol. 2012;12(1):5. doi:10.1186/1471-2415-12-5 16. Coleman AL, Yu F, Keeler E, Mangione CM. Treatment of uncorrected refractive error improves vision-specific quality of life. J Am Geriatr Soc. 2006;54(6):883–890. doi:10.1111/j.1532-5415.2006.00817.x 17. Owsley C, McGwin G Jr, Scilley K, Meek GC, Seker D, Dyer A. Effect of refractive error correction on health-related quality of life and depression in older nursing home residents. Arch Ophthalmol. 2007;125(11):1471–1477. doi:10.1001/archopht.125.11.1471 18. Gogate PM, Deshpande M, Wormald RP, Deshpande R, Kulkarni SR. Extracapsular cataract surgery compared with manual small incision cataract surgery in community eye care setting in western India: a randomised controlled trial. Br J Ophthalmol. 2003;87:667–672. doi:10.1136/ bjo.87.6.667 19. Hennig A. Sutureless non-phaco cataract surgery: a solution to reduce worldwide cataract blindness? Community Eye Health. 2003;16:49–51. 20. Astbury N. Converting from ECCE to SICS. Community Eye Health. 2009;22(69):6–7. 21. Gogate P. Clinical trials of manual small incision cataract surgery and standard extracapsular cataract surgery: results of quality of life. J Community Eye Health. 2003;16:5. 22. Calladine D, Evans JR, Shah S, Leyland M, Multifocal versus monofocal intraocular lenses after cataract extraction. Cochrane Database Syst Rev. 2012;133(9):CD003169. doi:10.1002/14651858.CD003169.pub3 23. Mencucci R, Cennamo M, Venturi D, Vignapiano R, Favuzza E. Visual outcome, optical quality, and patient satisfaction with a new monofocal IOL, enhanced for intermediate vision: preliminary results. J Cataract Refract Surg. 2020;46(3):378–387. doi:10.1097/j. jcrs.0000000000000061 24. Auffarth GU, Gerl M, Tsai L, et al. Clinical evaluation of a new monofocal intraocular lens with enhanced intermediate function in cataract patients. J Cataract Refract Surg. 2020. doi:10.1097/j.jcrs.0000000000000399 25. Lopes D, Loureiro T, Carreira R, et al. Comparative evaluation of visual outcomes after bilateral implantation of an advanced or conventional monofocal intraocular lens. Eur J Ophthalmol. 2021: 229–234. doi:10.1177/1120672121995343. 26. De luis Eguileor B, Martínez-Indart L, Martínez Alday N, Sacristán Egüén C, Cuadros Sánchez C. Differences in intermediate vision: monofocal intraocular lenses vs. monofocal extended depth of focus intraocular lenses. Arch Soc Esp Oftalmol. 2020;95(11):523–527. English, Spanish. doi:10.1016/j.oftal.2020.06.009 27. Cinar E, Bolu H, Erbakan G, et al. Vision outcomes with a new monofocal IOL. Int Ophthalmol. 2021;41(2):491–498. doi:10.1007/s10792-020- 01599-8 28. Yangzes S, Kamble N, Grewal S, Grewal SPS. Comparison of an aspheric monofocal intraocular lens with the new generation monofocal lens using defocus curve. Indian J Ophthalmol. 2020;68(12):3025–3029. doi:10.4103/ijo.IJO_985_20 29. Wan Y, Zhao L, Huang C, et al. Validation and comparison of the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) and the Visual Function Index-14 (VF-14) in patients with cataracts: a multicentre study [published online ahead of print, 2020 Sep 17]. Acta Ophthalmol. 2020;99(4):e480–e488. doi:10.1111/aos.14606 30. Elliott DB, Pesudovs K, Mallinson T. Vision-related quality of life. Optom Vis Sci. 2007;84(8):656–658. doi:10.1097/OPX.0b013e31814db01e 31. Longworth L, Yang Y, Young T, et al. Use of generic and condition-specific measures of health-related quality of life in NICE decision-making: systematic review, statistical modelling and survey. Health Technol Assess. 2014;18(9). doi:10.3310/hta18090. 32. McAlinden C, Gothwal VK, Khadka J, Wright TA, Lamoureux EL, Pesudovs K. A head-to-head comparison of 16 cataract surgery outcome questionnaires. Ophthalmology. 2011;118(12):2374–2381. doi:10.1016/j.ophtha.2011.06.008 33. Lundstrom M, Pesudovs K. Catquest-9SF patient outcomes questionnaire; nine-item short-form Rasch-scaled revision of the Catquest questionnaire. J Cataract Refract Surg. 2009;35(3):504–513. doi:10.1016/j.jcrs.2008.11.038 34. Sparrow JM, Grzeda MT, Frost NA, et al. Cat-PROM5: a brief psychometrically robust self-report questionnaire instrument for cataract surgery. Eye. 2018;32(4):796–805. doi:10.1038/eye.2018.1 Clinical Ophthalmology 2022:16 https://doi.org/10.2147/OPTH.S358386 1651 DovePress Powered by TCPDF (www.tcpdf.org) Blancafort Alias et al Dovepress 35. Teherani A, Martimianakis T, Stenfors-Hayes T, Wadhwa A, Varpio L. Choosing a qualitative research approach. J Grad Med Educ. 2015;7(4):669. doi:10.4300/JGME-D-15-00414.1 36. Atkinson MJ, Tally S, Heichel CW, Kozak I, Leich J, Levack A. A qualitative investigation of visual tasks with which to assess distance-specific visual function. Qual Life Res. 2013;22(2):437–453. doi:10.1007/s11136-012-0154-2 37. Iyigun E, Tastan S, Ayhan H, et al. Life experiences of patients with glaucoma: a phenomenological study. J Nurs Res. 2017;25(5):336–343. doi:10.1097/jnr.0000000000000172 38. Wu PX, Guo WY, Xia HO, Lu HJ, Xi SX. Patients’ experience of living with glaucoma: a phenomenological study. J Adv Nurs. 2011;67 (4):800–810. doi:10.1111/j.1365-2648.2010.05541.x 39. Prem Senthil M, Lim L, Braithwaite T, et al. The impact of adult uveitis on quality of life: an exploratory study. Ophthalmic Epidemiol. 2020:1–9. doi:10.1080/09286586.2020.1856385. 40. Groessl EJ, Liu L, Sklar M, Tally SR, Kaplan RM, Ganiats TG. Measuring the impact of cataract surgery on generic and vision-specific quality of life. Qual Life Res. 2013;22(6):1405–1414. doi:10.1007/s11136-012-0270-z 41. Fung SS, Luis J, Hussain B, Bunce C, Hingorani M, Hancox J. Patient-reported outcome measuring tools in cataract surgery: clinical comparison at a tertiary hospital. J Cataract Refract Surg. 2016;42(12):1759–1767. doi:10.1016/j.jcrs.2016.08.037 42. Massof RW, Rubin GS. Visual function assessment questionnaires. Surv Ophthalmol. 2001;45(6):531–548. doi:10.1016/S0039-6257(01)00194-1 43. Rentz AM, Kowalski JW, Walt JG, et al. Development of a preference-based index from the National Eye Institute Visual Function Questionnaire- 25. JAMA Ophthalmol. 2014;132(3):310–318. doi:10.1001/jamaophthalmol.2013.7639 44. Marella M, Pesudovs K, Keeffe JE, O’Connor PM, Rees G, Lamoureux EL. The psychometric validity of the NEI VFQ-25 for use in a low-vision population. Invest Ophthalmol Vis Sci. 2010;51(6):2878–2884. doi:10.1167/iovs.09-4494 45. Valderas JM, Rue M, Guyatt G, et al. The impact of the VF-14 index, a perceived visual function measure, in the routine management of cataract patients. Qual Life Res. 2005;14(7):1743–1753. doi:10.1007/s11136-005-1745-y 46. Gothwal VK, Reddy SP, Sumalini R, Bharani S, Bagga DK. National Eye Institute Visual Function Questionnaire or Indian Vision Function Questionnaire for visually impaired: a conundrum. Invest Ophthalmol Vis Sci. 2012;53(8):4730–4738. doi:10.1167/iovs.11-8776 47. Kovac B, Vukosavljevic M, Djokic Kovac J, et al. Validation and cross-cultural adaptation of the National Eye Institute Visual Function Questionnaire (NEI VFQ-25) in Serbian patients. Health Qual Life Outcomes. 2015;13(1):142. doi:10.1186/s12955-015-0330-5 48. Sparrow JM, Grzeda MT, Frost NA, et al. Cataract surgery patient-reported outcome measures: a head-to-head comparison of the psychometric performance and patient acceptability of the Cat-PROM5 and Catquest-9SF self-report questionnaires. Eye. 2018;32(4):788–795. doi:10.1038/ eye.2017.297 49. Lundström M, Pesudovs K. Catquest-9SF patient outcomes questionnaire: nine-item short-form Rasch-scaled revision of the Catquest questionnaire. J Cataract Refract Surg. 2009;35(3):504–513. doi:10.1016/j.jcrs.2008.11.038 50. Lundström M, Pesudovs K. Questionnaires for measuring cataract surgery outcomes. J Cataract Refract Surg. 2011;37(5):945–959. doi:10.1016/j. jcrs.2011.03.010 51. Gothwal VK, Wright TA, Lamoureux EL, Lundström M, Pesudovs K. Catquest questionnaire: re-validation in an Australian cataract population. Clin Exp Ophthalmol. 2009;37(8):785–794. doi:10.1111/j.1442-9071.2009.02133.x 52. Lundstrom MD, Llovet F, Llovet A, et al. Validation of the Spanish Catquest-9SF in patients with a monofocal or trifocal intraocular lens. J Cataract Refract Surg. 2016;42(12):1791–1796. doi:10.1016/j.jcrs.2016.10.011 53. Stone A, Kessler R, Haythornthwaite J. Measuring daily events and experiences: decisions for the researcher. J Pers. 1991;59(3):575–607. doi:10.1111/j.1467-6494.1991.tb00260.x Clinical Ophthalmology Dovepress Publish your work in this journal Clinical Ophthalmology is an international, peer-reviewed journal covering all subspecialties within ophthalmology. Key topics include: Optometry; Visual science; Pharmacology and drug therapy in eye diseases; Basic Sciences; Primary and Secondary eye care; Patient Safety and Quality of Care Improvements. This journal is indexed on PubMed Central and CAS, and is the official journal of The Society of Clinical Ophthalmology (SCO). The manuscript management system is completely online and includes a very quick and fair peer-review system, which is all easy to use. Visit http://www. dovepress.com/testimonials.php to read real quotes from published authors. Submit your manuscript here: https://www.dovepress.com/clinical-ophthalmology-journal 1652 DovePress Clinical Ophthalmology 2022:16 Powered by TCPDF (www.tcpdf.org)