We read with interest the extended report by Hassell et al¹ about the adverse effect of quality of life in mild visual impairment (<6/12) and worse. Their demonstration of the impact of age-related macular degeneration on quality-of-life indices is an important illustration of the difficulties experienced by visually impaired people.

We have reported a similar experience in West Glamorgan (Wales, UK).² Our study was comprised of 66 patients registered as blind/partially sighted (59.1% because of age-related macular degeneration). The demographic characteristics mirrored this study (mean age 81.33 (SD 9.87) years; 69.7% female). We used an alternative index to the impact of vision impairment (IVI) questionnaire, the National Eye Institute visual function questionnaire (NEI-VFQ 25).³ This has similar categories, including general health, general vision, ocular pain, near activities, distance activities, social functioning, mental health, role difficulties, dependency, colour vision and peripheral vision.

Hassell et al showed a statistically significant restriction in leisure and work, social and consumer interaction, and household and personal care difficulties between those with a mild/moderate impairment and those with severe impairment. This was our experience in the analogous categories of social functioning (NEI-VFQ score 36.49% for the blind vs 50% for the partially sighted; p<0.001) and dependency (NEI-VFQ score 30.07% for the blind vs 46.98% for the partially sighted; p<0.001). Furthermore, percentage scores in our study were <50% for all categories except general health, ocular pain and colour vision for blind and partially sighted people. None of the studies that have used the NEI-VFQ to determine the extent of visual function, have previously demonstrated mean scores as low as in our study.^4,5 Hassell et al¹ have, therefore, shown a worse quality of life in severely visually impaired people (<6/60), and also reinforced the important fact that all people with visual impairment experience difficulties.

A second interesting finding in their paper was the absence of correlation between duration of visual impairment and adaptation. We found that the NEI-VFQ scores for those living alone were better than those for individuals living with someone for numerous categories including near vision activities (20.9% vs 15.3%, p = 0.03), distant vision activities (27.9% vs 20.1%, p = 0.056) and dependency (46.3 vs 31.4%, p = 0.004; Williams GP, Pathak-Ray V and Austin MW, unpublished data, 2001).

This may imply that living alone forces people to adapt. We interpreted this finding with caution, however, as a number of people “living with someone” resided in a nursing/residential home. This may have occurred as a result of living alone, causing difficulties with coping in the first instance.

Finally, the paper by Hassell et al was undertaken before people had received low vision services. Depressingly, our study found that there was incomplete delivery of formal low visual aid assessment (n = 44, 66%); 70% of these people found the aids to be of use. We, therefore, agree with Hassell et al referral to low visual services should be considered, and adequate delivery and support is required for it to be effective.