Glaucoma and Associated Visual Acuity and Field Loss Significantly Affect Glaucoma-Specific Psychosocial Functioning

doi:10.1016/j.ophtha.2014.09.030

Ophthalmology

Volume 122, Issue 3, March 2015, Pages 494-501

https://doi.org/10.1016/j.ophtha.2014.09.030 Get rights and content

Objective

To examine the impact of glaucoma and visual acuity (VA) and visual field (VF) losses on psychosocial functioning (PF).

Design

Cross-sectional study.

Participants

We compared PF between 192 participants with bilateral glaucoma with VA or VF losses and 40 controls from a tertiary eye hospital clinic in Singapore.

Methods

Glaucoma was defined using the Hodapp-Anderson-Parish criteria. Four psychosocial outcomes of the Glaucoma Quality of Life 36 questionnaire were psychometrically assessed using Rasch analysis. Multivariate regression was performed to determine the independent impact of glaucoma and VA and VF losses on PF. The impact of VA and VF on PF were evaluated by restricted cubic spline analysis.

Main Outcome Measures

Anxiety, self-image, psychological well-being, and confidence in health care.

Results

The mean age of participants was 66.2±11.0 years, and 63% were male. In the better eye, VA and mean deviation were Snellen 20/25 and −8.89±6.52 dB, respectively. In multivariate models, glaucoma patients had 63.0% greater anxiety (95% confidence interval [CI], −66.0% to −61.2%; P < 0.001), 71.0% lower self-image (95% CI, −74.1% to −68.5%; P < 0.001), 38.3% less psychological well-being (95% CI, −37.4% to −39.0%; P < 0.001), and 32.4% reduced confidence in health care than patients without glaucoma. The worst VA and VF categories had the most reduced PF (range, 26.0% to 81.5%; P < 0.001 for all associations) compared with controls. With worsening VA, there was a linear increase in anxiety (P = 0.009) and decrease in self-image (P = 0.005). With worsening VF from 0 to −12.1 dB (P = 0.003), anxiety increased before plateauing. Self-image decreased as VF worsened from 0 to −10 dB (P < 0.001), and confidence in health care decreased when VF worsened from 0 to −9.3 dB (P = 0.008). However, self-image and confidence in health care actually improved at greater levels of VF loss beyond these thresholds.

Conclusion

Glaucoma negatively affects PF. Early stage glaucoma with mild VF loss adversely affects anxiety, self-image, and confidence in health care. As VA worsens in advanced glaucoma, anxiety further increases and self-image deteriorates. Ophthalmologists and glaucoma patients need to be aware that both VA and VF losses at different stages of glaucoma negatively impact PF.

Section snippets

Study Participants

This cross-sectional study recruited patients aged 50 years and older from the glaucoma clinics of the Singapore National Eye Centre, a tertiary eye hospital in Singapore. Participants were excluded if they have had any prior laser procedure, hospitalization, or ocular or nonocular surgery in the last 2 months. Participants were also excluded if they had other eye disease, such as age-related macular degeneration, diabetic retinopathy, myopic macular degeneration, or significant cataract.

Results

There were 192 bilateral glaucoma cases (82.7%) and 40 controls (17.3%). There were 108 primary open-angle glaucoma and 84 angle-closure glaucoma cases. Compared with our normal-sighted control group, those with glaucoma were generally older (mean age, 68.7±10.3 vs. 54.1±4.5 years; P < 0.001), were not working (71.5% vs. 40.0%; P < 0.001), reported lower educational levels (primary education or below, 57% vs. 29%; P < 0.001), and had a greater proportion with ≥2 medical comorbidities (16.4% vs.

Discussion

This study characterizes the impact of glaucoma and associated VA and VF losses on specific PF outcomes. Glaucoma patients had 63% greater anxiety, 71% lower self-image, 38% less psychological well-being, and 32% reduced confidence in health care compared with controls. The results indicate that in early stage glaucoma (i.e., at mild VF loss), when VF worsens, anxiety increases, whereas self-image and confidence in health care are reduced (Fig 4). In late-stage glaucoma (i.e., when VA is

Acknowledgments

The authors thank Dr Eva Fenwick, from the University of Melbourne, for her assistance in the preparation of this manuscript.

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The purpose of the current study was to systematically identify and evaluate existing patient-reported outcome measures (PROMs) for clinical glaucoma practice.
Understanding and incorporating patient preferences into decision-making is now recognized as critical for optimal resource allocation, especially in technologically advancing areas, such as minimally invasive surgeries. Patient-reported outcome measures are instruments designed to evaluate the health outcomes that are most important to patients. Despite their recognized importance, especially in the era of patient-centered care, their routine use in clinical settings remains low.
A systematic literature search was conducted in 6 databases (EMBASE, MEDLINE, PsycINFO, Scopus, BIOSIS, and Web of Science) from the date of inception. Studies were included in the qualitative review if they reported measurement properties of PROMs in adult patients with glaucoma. COnsensus-based Standards for the selection of health Measurement INstruments guidelines were used to assess the included PROMs. The study protocol is registered with PROSPERO (registration number: CRD42020176064).
The literature search yielded 2661 records. After deduplication, 1259 studies entered level 1 screening, and based on title and abstract review, 164 records proceeded to full-text screening. In 48 included studies, 70 instrument reports discuss 43 distinct instruments in 3 major categories: glaucoma-specific, vision-specific, and general health-related quality of life. Most used measures were glaucoma-specific (Glaucoma Quality of Life [GQL] and Glaucoma Symptom Scale [GSS]) and vision-specific (National Eye Institute Visual Function Questionnaire [NEI VFQ-25]). All 3 have sufficient validity (especially construct), with GQL and GSS having sufficient internal consistency, cross-cultural validity, and reliability, with reports suggesting high methodological quality.
The GQL, GSS, and NEI VFQ-25 are the 3 most used questionnaires in a research setting, having considerable validation in a patient population with glaucoma. Limited reports on interpretability, responsiveness, and feasibility in all 43 identified instruments make identifying a single optimal questionnaire for clinical use challenging and highlight the need for further studies.
Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
The impact of low vision on social function: The potential importance of lost visual social cues
2023, Journal of Optometry
Citation Excerpt :
Early symptoms of glaucoma (a disease that damages the optic nerve) include a loss of peripheral vision, but in more severe cases of the disease a large proportion of the visual field can be impacted. Once again, quality of life studies that have specifically examined scores associated with psychosocial function have found that glaucoma negatively affect psychosocial functioning, with a higher prevalence of generalized anxiety and depression,38–40 especially in those that lack social support.41 Consistent with the idea that difficulties in face recognition may contribute to depression, the psychosocial impacts of glaucoma are correlated with the extent of vision loss; With increasing glaucoma severity, at levels where face recognition is likely to be impaired, quality of life decreases and depression is more common.42
Visual cues usually play a vital role in social interaction. As well as being the primary cue for identifying other people, visual cues also provide crucial non-verbal social information via both facial expressions and body language. One consequence of vision loss is the need to rely on non-visual cues during social interaction. Although verbal cues can carry a significant amount of information, this information is often not available to an untrained listener. Here, we review the current literature examining potential ways that the loss of social information due to vision loss might impact social functioning. A large number of studies suggest that low vision and blindness is a risk factor for anxiety and depression. This relationship has been attributed to multiple factors, including anxiety about disease progression, and impairments to quality of life that include difficulties reading, and a lack of access to work and social activities. However, our review suggests a potential additional contributing factor to reduced quality of life that has been hitherto overlooked: blindness may make it more difficult to effectively engage in social interactions, due to a loss of visual information. The current literature suggests it might be worth considering training in voice discrimination and/or recognition when carrying out rehabilitative training in late blind individuals.
The ICD-10 Glaucoma Severity Score Underestimates the Extent of Glaucomatous Optic Nerve Damage
2022, American Journal of Ophthalmology
To evaluate the International Classification of Disease, Tenth Revision (ICD-10) codes used for glaucoma severity classification, which are based on the location of visual field (VF) defects; given the known poor sensitivity of the 24-2 visual field test to early disease and macular damage, we hypothesized that the ICD-10 codes would not accurately reflect the extent of glaucomatous damage.
Retrospective validity and reliability analysis.
We evaluated 80 eyes with glaucomatous optic neuropathy (GON). Masked reviewers assigned an ICD-10 severity grade based on 24-2 VF. Two additional masked examiners determined the presence of optical coherence tomography (OCT) structural damage in each hemifield and/or central 5 degrees to define an OCT-based equivalent ICD-10 classification.
A total of 80 eyes with GON were classified as mild, moderate and advanced in 15, 23, and 42 cases, respectively, based on the 24-2 VF, and in 6, 7, and 67 cases, respectively, based on OCT. The OCT classifications were more severe in 29 of 80 cases (36%). In 33 cases (41.3%), macular damage detected by OCT was missed by the 24-2. In 4 of 80 cases (5%), the VF overestimated the severity, likely due to variability of the 24-2 test.
The ICD-10 system relies solely on damage seen on the 24-2 and as provides a 24-2 functional score rather than a “glaucoma” severity score. OCT revealed wide variation of damage across grades, with a significant proportion of the eyes showing macular structural damage missed with the 24-2 VF. Adding OCT information to the ICD-10 system would help it to more accurately reflect the extent of glaucomatous damage.
Quality of Life in Adults with Childhood Glaucoma: An Interview Study
2022, Ophthalmology Glaucoma
Citation Excerpt :
These feelings have not yet been evaluated in adults with childhood glaucoma. Feeling misunderstood has been previously reported to contribute to a lower psychosocial well-being and self-image in individuals with adult-onset glaucoma.31,32 Lower self-image, however, was attributed to a fear of falling likely due to decreased visual ability, and feeling older due to the disease rather than the association between eye appearance and use of vision aids on self-image.
To explore and report on the quality-of-life (QoL) issues encountered by adults with childhood glaucoma.
Exploratory qualitative study.
Forty-seven participants with childhood glaucoma (defined as disease onset <18 years) recruited from the Australian and New Zealand Registry of Advanced Glaucoma (ANZRAG).
A qualitative research methodology (interpretive phenomenology) was applied, and data were collected through semistructured in-depth interviews. NVivo-12 software (QSR International Pty Ltd) was used to inductively analyze and code data to identify QoL themes pertinent to the cohort studied.
Quality-of-life themes and subthemes.
Mean participant age was 40.0 ± 15.3 years, and 55% of participants were female. We identified 10 QoL themes pertinent to adults living with childhood glaucoma. Coping strategies and emotional well-being were the most prominent themes. Maladaptive coping strategies, including treatment nonadherence, were observed more commonly in individuals aged <40 years and those without a vision impairment or reviewed less regularly. Emotional well-being was affected by feelings of being misunderstood because of the rarity of the condition, being self-conscious of physical manifestations of the disease, and anxiety related to possible disease progression and vision loss. The effect of childhood glaucoma on family planning formed a novel QoL theme and included worry for their child to inherit the condition and an inability to fulfill parental duties. This often led to genetic counseling–seeking behaviors. Mobility issues were infrequently experienced.
Childhood glaucoma poses a substantial impact to the emotional well-being of adults with the condition, which is mediated by the use of coping strategies. Genetic counseling and family planning options may be important. This study supports the development of a childhood glaucoma–specific patient-reported outcome measure for assessment of the psychosocial impact of childhood glaucoma in adults.
Using Uniocular Visual Acuity Substantially Underestimates the Impact of Visual Impairment on Quality of Life Compared with Binocular Visual Acuity
2020, Ophthalmology
Although the impact of vision-related quality of life (VRQoL) is assessed optimally using binocular visual acuity (VA), uniocular VA remains the preferred measurement method in clinic-based and epidemiologic studies. We compared the impact of distance presenting binocular VA and uniocular VA in the better-seeing (better-eye VA) and worse-seeing (worse-eye VA) eye on VRQoL.
The Singapore Chinese Eye Study 2 (2015–2017), a population-based, cross-sectional study.
One thousand eight hundred twenty-two individuals (mean age, 66.2 years [standard deviation, 8.9 years]; 51.1% women) were included.
Presenting uniocular VA and binocular VA were assessed using a logarithm of the minimum angle of resolution number chart at a distance of 4 m under standard lighting by trained and certified study optometrists. Multiple linear regression models were constructed to determine the independent associations between binocular VA, better-eye VA, and worse-eye VA and the outcome (VRQoL), adjusted for potential confounders, including age, gender, socioeconomic status, and presence of comorbidities. In addition, a cluster sandwich estimator was used to determine if any differences in β estimates between the associations were statistically significant.
Vision-related quality of life was measured using Rasch-transformed scores from the emotional, mobility, and reading domains of the Impact of Visual Impairment (IVI) questionnaire.
Although every 2-line increase (worsening) in binocular VA and uniocular VA was associated independently with decrements in emotional, mobility, and reading IVI scores (P < 0.05 for all), the reductions in all VRQoL domains were substantially lower (P < 0.1) when using either the better-eye VA (compared with binocular VA β-estimates, –27.8%, –19.4%, and –24.2% difference in emotional, mobility, and reading IVI scores, respectively) or worse-eye VA (compared with binocular VA β estimates, –38.9%, –58.1%, and –57.5% reduction in emotional, mobility, and reading IVI scores, respectively) to quantify vision loss.
Uniocular VA seems to underestimate the impact of vision loss on VRQoL indices compared with binocular VA. Our data suggest that researchers, clinicians, and policy planners should consider using binocular instead of uniocular measures of VA in patient-reported outcome evaluation of vision loss because it may better reflect its impact on VRQoL.
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2020, Progress in Retinal and Eye Research
Citation Excerpt :
Our population-based research in Singaporeans has revealed clinically significant decrements in emotional well-being, assessed using the Impact of Vision Impairment (IVI) questionnaire, when comparing those with and without glaucoma (Fig. 4) (Fenwick et al., 2017). Similarly, a clinical study of the association between glaucoma-related loss and psychosocial functioning using the 36-item GlauQoL questionnaire revealed that, compared to individuals without the disease, Singaporean people with glaucoma had 63% higher levels of anxiety, 71% lower levels of perceived self-image, 38% lower levels of emotional well-being, and 32% lower levels of confidence in healthcare (Chan et al., 2015). However, other studies have found no association between glaucoma or related vision loss and psychosocial outcomes (Rezapour et al., 2018; Wilson et al., 2002).
Glaucoma, an irreversible blinding condition affecting 3–4% adults aged above 40 years worldwide, is set to increase with a rapidly aging global population. Raised intraocular pressure (IOP) is a major risk factor for glaucoma where the treatment paradigm is focused on managing IOP using medications, laser, or surgery regimens. However, notwithstanding IOP and other clinical parameters, patient-reported outcomes, including daily functioning, emotional well-being, symptoms, mobility, and social life, remain the foremost concerns for people being treated for glaucoma. These outcomes are measured using objective patient-centered outcome measures (PCOMs) and subjective patient-reported outcome measures (PROMs). Studies using PCOMs have shown that people with glaucoma have several mobility, navigational and coordination challenges; reading and face recognition deficits; and are slower in adapting to multiple real-world situations when compared to healthy controls. Similarly, studies have consistently demonstrated, using PROMs, that glaucoma substantially and negatively impacts on peoples’ self-reported visual functioning, mobility, independence, emotional well-being, self-image, and confidence in healthcare, compared to healthy individuals, particularly in those with late-stage disease undergoing a heavy treatment regimen. The patient-centred effectiveness of current glaucoma treatment paradigms is equivocal due to a lack of well-designed randomized controlled trials; short post-treatment follow-up periods; an inappropriate selection or availability of PROMs; and/or an insensitivity of currently available PROMs to monitor changes especially in patients with newly diagnosed early-stage glaucoma. We provide a comprehensive, albeit non-systematic, critique of the psychometric properties, limitations, and recent advances of currently available glaucoma-specific PCOMs and PROMs. Finally, we propose that item banking and computerized adaptive testing methods can address the multiple limitations of paper-pencil PROMs; customize their administration; and have the potential to improve healthcare outcomes for people with glaucoma.

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: Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article.

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Original articleGlaucoma and Associated Visual Acuity and Field Loss Significantly Affect Glaucoma-Specific Psychosocial Functioning

Objective

Design

Participants

Methods

Main Outcome Measures

Results

Conclusion

Section snippets

Study Participants

Results

Discussion

Acknowledgments

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

J Psychosom Res

Ophthalmology

Ophthalmology

Ophthalmology

The number of people with glaucoma worldwide in 2010 and 2020

Br J Ophthalmol

Prevalence of open-angle glaucoma among adults in the United States

Arch Ophthalmol

The prevalence and types of glaucoma in Malay people: the Singapore Malay Eye Study

Invest Ophthalmol Vis Sci

The prevalence of glaucoma in Chinese residents of Singapore: a cross-sectional population survey

Arch Ophthalmol

The prevalence and types of glaucoma in an urban Indian population: the Singapore Indian Eye Study

Invest Ophthalmol Vis Sci

Impact of glaucoma severity and laterality on vision-specific functioning: the Singapore Malay Eye Study

Invest Ophthalmol Vis Sci

Impact of visual field loss and health-related quality of life in glaucoma: the Los Angeles Latino Eye Study

Ophthalmology

How does visual impairment affect performance on tasks of everyday life? The SEE Project

Arch Ophthalmol

Association of vision loss in glaucoma and age-related macular degeneration with IADL disability

Invest Ophthalmol Vis Sci

Difficulty with out-loud and silent reading in glaucoma

Invest Ophthalmol Vis Sci

Prevalence and predictors of depression among participants with glaucoma in a nationally representative population sample

Am J Ophthalmol

Impact of vision loss on costs and outcomes in Medicare beneficiaries with glaucoma

Arch Ophthalmol

Original article
Glaucoma and Associated Visual Acuity and Field Loss Significantly Affect Glaucoma-Specific Psychosocial Functioning