Presence of Diabetic Retinopathy Worsens Vision-Related Quality of Life

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As diabetic retinopathy severity progresses, both vision-related and health-related scales show a significant deterioration in quality of life scores.

Vision-related quality of life (VRQoL) diminished with the presence of diabetic retinopathy (DR), and worsened further with increasing disease severity, according to a new systematic review and meta-analysis.1

The study assessed up-to-date evidence on the association between DR and VRQoL and general health related QoL (HRQoL) scales across 4 medical databases. After analysis, vision specific QoL scales showed greater sensitivity in identifying the functional deficit associated with DR versus general HRQoL scales.

“Our results also show that the effect at early DR stages is better captured using VRQoL scales as opposed to general HRQoL scales, as previously reported,” wrote the investigative team, led by Mohammed G. Zayed, MSc, clinical trials service unit in the Nuffield Department of Population Health, University of Oxford. “However, as the DR severity progresses, a significant deterioration of QoL scores is seen using both VRQoL and HRQoL scales.”

Clinical measures, such as VA, can be a poor indicator of visual function in certain populations with DR.2 Instead, patient-reported outcome measures may provide a greater understanding of functional deficits from the patients’ perspectives. Health-related QoL scales can be relevant to a population with or without a chronic illness, or assess specific challenges in a patient population, including VRQoL.

However, Zayed and colleagues indicated the limitations of previous reviews of the literature on the association between QoL and DR.1 For this analysis, the team searched the MEDLINE, EBSCO, Embase, and Web of Science databases using a predefined search strategy from inception to April 2022.

Each database was screened based on titles and abstracts, with full-text versions classified as eligible or ineligible by 2 independent reviewers. Reviewers then assessed the risk of bias using the 14-item standard quality assessment of primary research articles. Two assumption-free meta-analyses were performed to avoid biases related to small-study effects.

A total of 7767 articles were identified and 93 met inclusion criteria, including 73 observational studies and 20 interventional studies. Of the studies, 54 recorded VRQoL, 26 recorded HRQoL, and both were recorded in 13 studies. In total, data for 39,989 participants (29,467 with DR and 10,522 without DR) were included for analysis.

Most studies (n = 49) used the National Eye Institute 25-item Visual Function Questionnaire (VFQ-25) for VRQoL and the Short Form Health Survey (n = 18) for HRQoL. Analysis 1 included studies with participants without DR as the referent group for comparison of QoL scores of participants with DR, separated by DR severity. Analysis 2 involved all studies with participants with DR and a measure of QoL.

The composite score analysis in Analysis 1 included 8 studies with 1138 participants with DR and 347 participants without DR. In comparison to individuals without DR, the analysis showed the composite VFQ-25 score was 3.8 (95% CI, 1.0 - 6.7) points lower in those with non–vision-threatening DR (NVTDR), 12.5 (95% CI, 8.5 - 16.5) lower in those with any DR, and 25.1 (95% CI, 22.8 - 27.2) lower in VTDR (P <.001 for trend).

A total of 35 studies reported VFQ-25 composite scores in Analysis 2, involving 6351 participants with DR. Upon analysis, the pooled mean VFQ-25 composite score was 91.8 (95% CI, 91.0 - 92.7) for individuals with NVTDR, 77.6 (95% CI, 76.9 - 78.3) for any DR, and 73.2 (95% CI, 72.6 - 73.7) for VTDR (P <.001 for trend).

Meta-regression models were used to analyze confounders between DR and pooled VFQ-25 composite scores, with analyses finding older age, male sex, and worse VA were associated with lower composite scores. After multivariable meta-regression, only VA remained statistically significant when considering all DR severity types. However, Zayed and colleagues noted the VFQ-25 composite scores still declined in patients with VTDR after adjusting for VA.

“After controlling for VA, the deterioration in VRQoL associated with increasing severity of DR remained significant, suggesting that the association of DR with QoL is not fully explained by its effect on VA,” investigators wrote.


  1. Zayed MG, Karsan W, Peto T, Saravanan P, Virgili G, Preiss D. Diabetic Retinopathy and Quality of Life: A Systematic Review and Meta-Analysis. JAMA Ophthalmol. Published online February 01, 2024. doi:10.1001/jamaophthalmol.2023.6435
  2. Chen XD, Gardner TW. Patient-reported outcomes reveal impairments not explained by psychophysical testing in patients with regressed PDR. Transl Vis Sci Technol. 2019;8(4):11. doi:10.1167/tvst.8.4.11