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Inter-relationship between visual symptoms, activity limitation and psychological functioning in patients with diabetic retinopathy
  1. Eva K Fenwick1,2,3,
  2. Grand H-L Cheng3,
  3. Ryan E K Man2,
  4. Jyoti Khadka4,
  5. Gwyn Rees1,
  6. Tien Y Wong2,3,
  7. Konrad Pesudovs4,
  8. Ecosse Luc Lamoureux1,2,3
  1. 1 Centre for Eye Research Australia, University of Melbourne, the Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia
  2. 2 Population Health, Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
  3. 3 Duke–NUS, National University of Singapore, Singapore, Singapore
  4. 4 Discipline of Optometry, Flinders University of South Australia, Australia
  1. Correspondence to Professor Ecosse Luc Lamoureux, Singapore Eye Research Institute (SERI) Director, Population HealthThe Academia, 20 College Road, Level 6, Singapore 169856; ecosse.lamoureux{at}


Aims We explored the direct and indirect impact of restrictions in daily living activities on the relationship between perceived visual symptoms associated with diabetic retinopathy (DR) and psychological functioning.

Methods In this prospective, cross-sectional study, 514 tertiary patients with DR (mean age±SD, 60.4±12.6 years; 64% male) answered questions related to nine domains of DR-specific quality of life. These were classified into the following predictor, mediating and outcome variables: visual symptoms (predictor variable); activity limitation, driving, lighting, social restriction, inconvenience, mobility (mediating variables); and emotional distress and concerns (outcome variables). Direct and indirect relationships between study variables were assessed using path analysis, using interval-level person measures derived from Rasch analyses of the study questionnaires.

Results We found no direct effect of DR-related visual symptoms on emotional distress or concerns. Rather, the association between visual symptoms and emotional distress was mediated (all p<0.05) by mobility (indirect effect=0.07), inconvenience (indirect effect=0.28), activity limitation (indirect effect=0.13) and social restriction (indirect effect=0.11). Similarly, the relationship between DR-related visual symptoms and concerns was mediated by inconvenience (indirect effect=0.36) and social restriction (indirect effect=0.11). Lighting and driving did not have a mediating role.

Conclusions The link between vision and psychological functioning outcomes such as emotional distress and concern is complex in patients with DR and mediated by limitations in daily living activities and social factors. Interventions to enhance daily functioning and social interaction may be effective in reducing emotional distress associated with DR-related vision impairment.

  • Retina
  • Vision
  • Visual Perception
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  • Contributors EKF and REKM contributed to the conception of the work, interpretation of the data and drafting of the manuscript; EKF and GHLC conducted the data analysis, assisted with interpretation of results and drafted sections of the paper; JK, GR, KP and TYW revised the manuscript critically for important intellectual content; ELL contributed to the conception of the work, interpretation of the data and revised the manuscript critically for important intellectual content.

  • Funding This work was supported by National Health and Medical Research Council Centre for Clinical Research Excellence (CCRE) #529923–Translational Clinical Research in Major Eye Diseases; CCRE Diabetes; Novartis Pharmaceuticals Australia #CRFB002DAU09T; Royal Victorian Eye and Ear Hospital; EKF was funded by the Australian National Health and Medical Research Council (NHMRC) Early Career Fellowship (#1072987). GR is funded by an NHMRC Career Development Award (#1061801) The Centre for Eye Research Australia receives Operational Infrastructure Support from the Victorian Government. The sponsor or funding organisation had no role in the design or conduct of this research.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval The Royal Victorian Eye and Ear Hospital Human Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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