The Association Between Glaucoma, Anxiety, and Depression in a Large Population

Coinheritance of OLFM2 and SIX6 variants in a Chinese family with juvenile-onset primary open-angle glaucoma: A case report

BACKGROUND

Juvenile-onset primary open-angle glaucoma (JOAG), characterized by severe elevation of intraocular pressure and optic neuropathy prior to the age of 40, is a rare subtype of primary open-angle glaucoma. Several genetic mutations have been associated with JOAG.

CASE SUMMARY

The proband patient was a young male, diagnosed with primary open-angle glaucoma at the age of 27. The patient and his unaffected parents who have been excluded from classic genetic mutations for primary open-angle glaucoma were included to explore for other possible genetic variants through whole genome sequencing and bioinformatics analysis. In this trio, we found two heterozygous variants inherited from the parents in the proband: c.281G>A, p.Arg94His in OLFM2 and c.177C>G, p.Ile59Met in SIX6. Both genetic mutations are predicted through bioinformatics analysis to replace evolutionary conserved amino acids, therefore rendering a pathogenic effect on proteins. In contrast, very low frequencies for these genetic mutations were recorded in most common control databases.

CONCLUSION

This is the first report on coinherited mutations of OLFM2 and SIX6 in a JOAG family, which shows the complexity of JOAG inheritance. Large-scale clinical screening and molecular functional investigations on these coinherited mutations are imperative to improve our understanding of the development of JOAG.

The effect of anxiety and depression on progression of glaucoma

Glaucoma is considered a chronic disease that requires lifelong management. Chronic diseases are known to be highly associated with psychological disturbances such as depression and anxiety. There have also been many studies on association between anxiety or depression and glaucoma. The majority of these studies explained that the glaucoma diagnosis causes anxiety or depression. However, It is also necessary to evaluate whether the psychological disturbance itself affect glaucoma. Therefore, we investigated the association of anxiety and depression with glaucoma progression, and elucidate mechanisms underlying that. We included 251 eyes with open angle glaucoma who were followed up for at least 2 years in this retrospective case-control study. The Beck Anxiety Inventory (BAI) and Beck Depressive Inventory-II (BDI-II) were used to assess anxiety and depression in glaucoma patients. Patients were classified into groups (high-anxiety group; HA-G, low-anxiety group; LA-G, high-depression group; HD-G, low-depression group; LD-G) according to their score on the BAI or BDI-II (separately). In logistic regression analysis, disc hemorrhage, peak intraocular pressure (IOP) and RNFL thickness loss rate were significantly associated with high anxiety (p = 0.017, p = 0.046, p = 0.026). RNFL thinning rate and disc hemorrhage were significant factors associated with anxiety in multivariate models (p = 0.015, p = 0.019). Multivariate linear regression analysis showed a significant positive correlation between the rate of RNFL thickness loss and BAI score (B = 0.058; 95% confidential interval = 0.020-0.097; p = 0.003), and RNFL loss and IOP fluctuation (B = 0.092; 95% confidential interval = 0.030-0.154; p = 0.004). For the depression scale, visual field mean deviation and heart rate variability were significantly associated with high depression in multivariate logistic regression analysis (p = 0.003, p = 0.006). We suggest that anxiety increase the risk of glaucoma progression and they are also associated with IOP profile and disc hemorrhage.

Assessment of Reasons for Presentation in New Primary Glaucoma Patients and Identification of Risk Factors for Late Presentation

PURPOSE

To evaluate the reasons for seeking care among South Indian primary glaucoma patients and to determine the relationship of various patient characteristics to glaucoma severity at presentation.

DESIGN

Cross-sectional study.

PARTICIPANTS

One hundred sixty-one new primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG) patients seeking treatment at a tertiary eye hospital.

METHODS

After confirmation of diagnosis, participants' clinical information and their reported reasons for presentation were assessed. Data collected include age, gender, education, occupation, rural or urban residence, distance traveled to the hospital, method of transportation, need for an accompanying person, place of screening before referral or whether they came by themselves for testing. Advanced glaucoma was defined by a cup-to-disc ratio of 0.85 or higher in either eye.

MAIN OUTCOME MEASURES

The primary outcomes were the various reasons for presentation. The secondary outcome was to determine whether a relationship existed between the patient characteristics mentioned above and presentation with advanced glaucoma.

RESULTS

The mean age of the participants was 60.8 years. The primary reason for presentation was defective vision (55.2%) followed by routine ophthalmic evaluation (13%). Sixty-four patients (39.8%) showed advanced glaucoma in at least 1 eye at presentation. Unilateral blindness was noted in 18 patients (11.2%). The mean vertical cup-to-disc ratio was 0.66 (standard deviation [SD], ±0.16) in the better-seeing eye and 0.76 (SD, ±0.12) in the worse-seeing eye. The mean presenting intraocular pressure was 22.9 mmHg in POAG and 25.5 mmHg in PACG patients. Multivariate logistic regression analyses showed that people who are currently unemployed (P < 0.001; odds ratio [OR], 4.19; 95% confidence interval [CI], 1.95-8.99) and rural residence (P = 0.04; OR, 0.46; 95% CI, 0.21-0.99) had greater odds of demonstrating advanced glaucoma at presentation. Presentation with defective vision, older age, and education less than college graduation were associated with greater odds of showing advanced glaucoma in univariate analysis, but not in multivariate analyses.

CONCLUSIONS

In a South Indian population, absence of work and rural residence was associated with advanced glaucoma at presentation. The population in whom these risk factors are common should be targeted for screening and outreach.

Impact of Vision Loss on Visual Function Among Elderly Residents in the "Home for the Aged" in India: The Hyderabad Ocular Morbidity in Elderly Study

Purpose

The purpose of this study was to report the association between visual impairment (VI) and self-reported visual difficulty among the elderly in residential care using the Indian Vision Functioning Questionnaire (IND-VFQ-33) psychometrically validated questionnaire.

Methods

Participants aged ≥ 60 years were recruited from 41 homes in Hyderabad in South India. All participants underwent detailed eye examination and interviews. Self-reported visual function was assessed using the IND-VFQ-33 questionnaire. Factor Analysis and Item Response Theory (IRT) models were used for analysis. Multivariable regression models were used to investigate associations between derived global difficulty scores versus severity and causes of VI. Presenting visual acuity worse than 6/18 in the better eye was considered as VI.

Results

In total, 867 elderly participants completed the INDVFQ-33. Two latent traits ("daily activities" and "visual symptoms") were identified on factor analysis, each with uniquely loading questions. Participants with VI reported significantly higher daily activities difficulty (6 points higher) and visual symptoms difficulty (1.7 points higher) than those without VI (P < 0.05). Those with cataract reported the highest daily activities and visual symptoms difficulty (7.6 points and 2.2 points higher, respectively, P < 0.05). Greater severity of VI was associated with increased self-reported difficulty for both factors, and for all causes of VI.

Conclusions

We present a psychometrically validated visual questionnaire particularly suited to older adults in residential homes. We show a significant association between cause/severity of VI and difficulty with daily activities and visual symptoms after adjusting for sociodemographic and medical factors.

Translational Relevance

Understanding the impact of vision loss on visual functions in the elderly will help in planning and resource allocation for developing early intervention programs for the elderly.

Can Psychologic Stress Elevate Intraocular Pressure in Healthy Individuals?

PURPOSE

To investigate if a stress event can influence intraocular pressure (IOP) in a group of healthy individuals.

DESIGN

Case-control study.

PARTICIPANTS

A total of 28 healthy subjects were included: 17 in the stress group and 11 in the control group.

METHODS

The Trier Social Stress Test (TSST) is a tool to evaluate cortisol response to psychologic stimulation based on the stress induced by public speaking. All participants underwent a modified diurnal tension curve (DTC) 1 week before the TSST, with 3 IOP measurements performed between 8:00 am and 2:00 pm. We evaluated the response to the TSST measuring the levels of salivary cortisol, IOP, and heart rate before, immediately after, and 40 minutes after TSST. The State Trait Anxiety Inventory (STAI) was applied to evaluate the levels of anxiety at the same time intervals.

MAIN OUTCOME MEASURES

Changes in IOP (mmHg), salivary cortisol, heart rate, and STAI scores.

RESULTS

At baseline, there were no significant differences between case and controls regarding age (52.2 ± 6.26 vs. 53.8 ± 8.4 years, P = 0.661), gender (52.94% male vs. 45.45% female, P = 0.669), and ethnicity. Salivary cortisol (6.8 nmol/l, P < 0.001) and heart rate (7.2 beats/min, P = 0.035) increased significantly after the TSST. We observed a mean IOP increase of 1.0 mmHg (right eye, P = 0.003) and 1.1 mmHg (left eye, P = 0.004) when comparing IOP measurements obtained during the DTC and immediately after TSST. In addition, 35% (6/17) of the subjects in the TSST group showed an IOP increase higher than 2 mmHg after the test compared with 18% (2/11) in the control group. The STAI state score significantly increased after the stress event compared with baseline (P = 0.026) and decreased from poststress to the recovery period (P = 0.006) in the TSST group. The control group did not show significant changes in IOP, heart rate, salivary cortisol levels, and STAI scores.

CONCLUSIONS

Significant elevations of IOP, salivary cortisol, STAI scores, and heart rate occurred after inducing psychologic stress with TSST in a group of healthy individuals.

Association of ocular diseases with schizophrenia, bipolar disorder, and major depressive disorder: a retrospective case-control, population-based study

BACKGROUND

Psychiatric disorders and ocular neurovascular diseases may share a similar pathophysiological route of vascular structures or neurological changes. The aim of this study is to investigate the association between ocular neurovascular diseases and the risk of major psychiatric disorders.

METHODS

This was a retrospective case-control, population-based study including patients aged ≥20 and were diagnosed between 1997 and 2013. Ocular neurovascular diseases diagnosed between 1997 and 2006 and newly diagnosed psychiatric disorders including bipolar disorder (BD), major depressive disorder (MDD), and schizophrenia between 2007 and 2013 were registered. Patients were propensity-score matched with control groups without psychiatric disorders in each cohort based on selected covariates.

RESULTS

A total of one million sampled patients in the database were categorized based on their diagnoses; 2243 (37.4% men) were categorized into the BD group, 10,110 (35.2% men) into the MDD group, and 1623 (43.1% men) into the schizophrenia group. In the BD group, all glaucoma (OR 1.49, [1.18-1.89]), open-angle glaucoma (OR 2.08, [1.34-3.24]), and closed-angle glaucoma (OR 2.12, [1.36-3.33]) showed statistical significance of risk. In the MDD group, age-related macular degeneration (OR 1.33, [1.13-1.57]), all glaucoma (OR 1.24, [1.11-1.37]), open-angle glaucoma (OR 1.47, [1.21-1.80]), and dry eye syndrome (OR 1.22, [1.13-1.31]) were associated with a significantly higher risk. In the schizophrenia group, only all glaucoma (OR 1.47, [1.02-2.11]), glaucoma suspect (OR 1.88, [1.01-3.49]), and open-angle glaucoma (OR 2.19, [1.13-4.26]) showed statistical significance.

CONCLUSIONS

In this population-based study, ocular neurovascular diseases, especially glaucoma, were associated with increased risks of BD, MDD, and schizophrenia.

Impact of Video Education on Patient Knowledge, Anxiety, and Satisfaction in Selective Laser Trabeculoplasty: A Pilot Study

PRéCIS:: In patients undergoing selective laser trabeculoplasty, preoperative video education did not improve patient knowledge regarding the procedure, decrease anxiety, or increase satisfaction, as these metrics were already favorable across all patients in this study.

PURPOSE

To assess the effect of an educational video on patient knowledge, anxiety, and satisfaction at a selective laser trabeculoplasty (SLT) procedure visit.

MATERIALS AND METHODS

This is a prospective, randomized trial. Patients at a single academic medical center completed a survey at their procedure visit for SLT; patients were randomized to view an educational video or no video before survey administration. Knowledge was assessed with a 10-item questionnaire. The 6-item State-Trait Anxiety Inventory scale (STAI-6) assessed anxiety (score >40 defined significant anxiety). Perceptions of visit quality were assessed using a Likert scale.

RESULTS

Twenty-two patients were randomized into video (n=11) and control (n=11) groups. No difference in knowledge was observed between groups (83.6% control vs. 82.7% video group, P=0.635). No patient had significant anxiety (STAI-6 range, 20 to 40, average 29) and scores were similar between groups (P=0.385). Overall, patients had positive perceptions of visit quality, and there was no significant difference between groups (P=0.999).

CONCLUSION

Patients undergoing SLT had high levels of knowledge, low levels of anxiety, and high levels of satisfaction. In this clinical setting, an educational video seemed to have no additional benefit on these metrics and thus, may be omitted. Further research may be directed toward optimizing patient education regarding SLT, particularly in settings with poor health literacy, limited resources, or limited access to glaucoma specialists.

Reorganization of the structural connectome in primary open angle Glaucoma

Primary open angle Glaucoma (POAG) is one of the most common causes of permanent blindness in the world. Recent studies have suggested the hypothesis that POAG is also a central nervous system disorder which may result in additional (i.e., extra-ocular) involvement. The aim of this study is to assess possible structural, whole-brain connectivity alterations in POAG patients. We evaluated 23 POAG patients and 15 healthy controls by combining multi-shell diffusion weighted imaging, multi-shell, multi-tissue probabilistic tractography, graph theoretical measures and a recently designed 'disruption index', which evaluates the global reorganization of brain networks. We also studied the associations between the whole-brain structural connectivity measures and indices of visual acuity including the field index (VFI) and two Optical Coherence Tomography (OCT) parameters, namely the Macula Ganglion Cell Layer (MaculaGCL) and Retinal Nerve Fiber Layer (RNFL) thicknesses. We found both global and local structural connectivity differences between POAG patients and controls, which extended well beyond the primary visual pathway and were localized in the left calcarine gyrus (clustering coefficient p = 0.036), left lateral occipital cortex (clustering coefficient p = 0.017, local efficiency p = 0.035), right lingual gyrus (clustering coefficient p = 0.009), and right paracentral lobule (clustering coefficient p = 0.009, local efficiency p = 0.018). Group-wise (clustering coefficient, p = 6.59∙10-7 and local efficiency p = 6.23·10-8) and subject-wise disruption indices (clustering coefficient, p = 0.018 and local efficiency, p = 0.01) also differed between POAG patients and controls. In addition, we found negative associations between RNFL thickness and local measures (clustering coefficient, local efficiency and strength) in the right amygdala (local efficiency p = 0.008, local strength p = 0.016), right inferior temporal gyrus (clustering coefficient p = 0.036, local efficiency p = 0.042), and right temporal pole (local strength p = 0.008). Overall, we show, in patients with POAG, a whole-brain structural reorganization that spans across a variety of brain regions involved in visual processing, motor control, and emotional/cognitive functions. We also identified a pattern of brain structural changes in relation to POAG clinical severity. Taken together, our findings support the hypothesis that the reduction in visual acuity from POAG can be driven by a combination of local (i.e., in the eye) and more extended (i.e., brain) effects.

Economic Hardship, Ocular Complications, and Poor Self-reported Visual Function are Predictors of Mental Problems in Patients with Uveitis

PURPOSE

To characterize the quality of life and mental health status of patients with uveitis and investigate predictors of psychological problems.

METHODS

A total of 245 patients and 105 controls were enrolled in this cross-sectional study. Quality of life, psychological status, socio-demographic and clinical data were obtained from questionnaires and medical records. Multivariate regression analyses and Receiver Operating Characteristic (ROC) were applied to obtain the model predicting psychological problems of patients.

RESULTS

Of 245 patients, 16.7% and 26.5% (P < .0001) screened positive for anxiety and depression, respectively. The model predicting anxiety was comprised of low annual household income and poor self-reported visual function (P = .029, P < .0001, respectively), with an AUC of ROC of 0.744. The model predicting depression was comprised of poor self-reported visual function and ocular complications (P < .0001, P = .012, respectively), with an AUC of 0.78.

CONCLUSIONS

Economic hardship, ocular complications, and poor self-reported visual function are predictors of mental problems in patients with uveitis.

Impact of Visual Field Testing on Intraocular Pressure Change Trends in Healthy People and Glaucoma Patients

PURPOSE

To compare the impact of visual field (VF) testing on intraocular pressure (IOP) change trends between healthy subjects and glaucoma patients.

METHODS

We recruited healthy volunteer subjects who did not have previous ocular diseases and open-angle glaucoma patients who were medically controlled well. IOP in both eyes of each participant was measured by using a noncontact tonometer at five time points: before, immediately after (0 minute), and 10, 30, and 60 minutes after the standard automated perimetry. Repeated measures ANOVA was used to analyze the effect of VF testing on IOP change trends in healthy and glaucoma eyes.

RESULTS

Forty healthy subjects (80 eyes) and 31 open-angle glaucoma patients (62 eyes) were included for the study. The baseline IOP of healthy and glaucoma eyes was 16.11 ± 3.01 mmHg and 15.78 ± 3.57 mmHg, respectively. After the VF testing, the IOP in healthy eyes was decreased by 1.5% at 0 minute, 6.5% at 10 minutes (P < 0.001), 6.6% at 30 minutes (P < 0.001), and 7.0% at 1 hour (P < 0.001), indicating that this reduction was sustained for at least 1 hour. However, the IOP in glaucoma eyes was increased by 12.7% at 0 minute (P < 0.001) and, then, returned towards initial values 1 hour after the VF testing.

CONCLUSIONS

IOP change trends after VF field testing between healthy subjects and glaucoma patients were quite different. VF testing led to a mild and relatively sustained IOP decrease in healthy subjects, whereas IOP in open-angle glaucoma patients tended to significantly increase immediately after VF testing and, then, returned to pretest values after 1 hour. These findings indicate that the factors of VF testing should be considered in the clinical IOP measurements.

Mood and behavior seasonality in glaucoma; assessing correlations between seasonality and structure and function of the retinal ganglion cells

Aim

In glaucoma, depression and disturbed sleep has been associated with degeneration of the intrinsically photosensitive retinal ganglion cells, that mediate non-image forming effects of light such as regulation of circadian rhythm, alertness and mood. In this study we assessed associations between seasonal mood and behavior variation and retinal ganglion cell damage in outpatients with glaucoma.

Methods

The seasonal pattern assessment questionnaire was administered to outpatients with glaucoma. Data on visual field defects identified by autoperimetry and retinal nerve fiber layer thickness visualized by ocular coherence tomography were collected from patient charts. The correlations between seasonality and retinal damage were tested and the adjusted effects of retinal function on seasonality were evaluated in a linear regression model.

Results

In total, 113 persons completed the questionnaire. Of these, 4% fulfilled the criteria for seasonal affective disorder (SAD) and 8% for subsyndromal seasonal affective disorder (sSAD). Mean global seasonal score was 4.3. There were no significant correlations between seasonality and either visual field or retinal nerve fiber layer thickness. In the adjusted analysis there were trends toward differential effects of visual field on seasonality in subgroups with different sex and type of glaucoma.

Conclusion

There were no strong associations between seasonality and visual field or retinal nerve fiber layer thickness. Sex, age and glaucoma subtype may modify light effects on complex regulatory systems.

Association Between Dry Eye Disease and Migraine Headaches in a Large Population-Based Study

Importance

Reports in the literature have conflicting findings about an association between dry eye disease (DED) and migraine headaches.

Objective

To determine the strength of the association between DED and migraine headaches.

Design, Setting, and Participants

This retrospective case-control study included 72 969 patients older than 18 years from University of North Carolina-affiliated health care facilities from May 1, 2008, through May 31, 2018. Deidentified aggregate patient data were queried; data were analyzed from June 1 through June 30, 2018.

Exposures

Diagnosis of migraine headache.

Main Outcomes and Measures

Odds ratios calculated between DED and migraine headaches for participants as a whole and stratified by sex and age group.

Results

The base population consisted of 72 969 patients, including 41 764 men (57.2%) and 31 205 women (42.8%). Of these, 5352 patients (7.3%) carried a diagnosis of migraine headache, and 9638 (13.2%) carried a diagnosis of DED. The odds of having DED given a diagnosis of migraine headaches was 1.72 (95% CI, 1.60-1.85) times higher than that of patients without migraine headaches. After accounting for multiple confounding factors, the odds of having DED given a diagnosis of migraine headaches was 1.42 (95% CI, 1.20-1.68) times higher than that of patients without migraine headaches.

Conclusions and Relevance

These findings suggest that patients with migraine headaches are more likely to have comorbid DED compared with the general population. Although this association may not reflect cause and effect if unidentified confounders account for the results, these data suggest that patients with migraine headaches may be at risk of carrying a comorbid diagnosis of DED.

Advanced glaucoma at diagnosis: current perspectives

Presentation with advanced glaucoma is a significant risk factor for lifetime blindness. The asymptomatic nature of glaucoma, particularly in early disease, means that substantial vision loss in one eye does not always translate into a perceptible loss of visual function. This, along with the lack of an effective screening strategy, contributes to late presentation. Those most at risk of presenting with advanced glaucoma have asymptomatic high intraocular pressure (IOP), no family history of glaucoma, are socially disadvantaged, and do not attend sight testing. Patients with glaucoma may have impaired functionality for daily activities, such as reading, walking and driving. Quality of life measures have shown this to be significantly worse in patients with more severe visual field loss, particularly if bilateral. In addition, quality of life decreases faster with further bilateral visual field loss when advanced visual field damage is present. Management of these patients requires disproportionally more resources than those with earlier disease. Both medical and surgical options are used as the initial approach to treat patients presenting with advanced glaucoma. The most recently published National Institute for Health and Care Excellence (NICE) guidelines suggest that patients presenting with advanced disease should be offered trabeculectomy as a primary intervention. However, more evidence is required to determine the best initial management. The Treatment of Advanced Glaucoma Study (TAGS) is being conducted, comparing primary medical management with primary mitomycin C-augmented trabeculectomy for people presenting with advanced open-angle glaucoma. The results of TAGS will provide robust evidence for the most appropriate initial intervention.

The impact of glaucoma on the mental health of primary open-angle glaucoma patients attending a teaching hospital in South East Nigeria

Objective:

To evaluate the effect of glaucoma on the mental health of primary open-angle glaucoma patients using Hospital Anxiety and Depression Scale (HADS)

Materials and Methods:

This was a hospital-based comparative study in which 180 glaucoma patients and controls 18 years and above who met the inclusion criteria were selected consecutively in the Eye Clinic of Federal Medical Centre, Owerri, Imo State, in 2017. Data were collected using a questionnaire and the HADS protocol. All the participants underwent comprehensive ocular examination, and glaucoma was graded using visual field perimetric indices and mean deviation.

Results:

The mean age for cases was 58.14 ± 13.88 years, whereas that of the control group was 57.19 ± 13.76 years. The majority of glaucoma respondents had the moderate form of the disease followed by the severe form. The glaucoma patients showed evidence of poor mental health with 59 (32.8%) of them anxious and 39 (21.7%) depressed compared to controls (P < 0.001). The mean scores for anxiety and depression were 6.02 ± 4.8 and 5.20 ± 4.5, respectively, for glaucoma patients, whereas those for the control group were 0.63 ± 1.8 and 0.64 ± 2.1, respectively (P < 0.001). There was no uniform correlation between the mental health of patients and the variables under study.

Conclusion:

Primary open-angle glaucoma affects the mental health of patients. This effect is worsened by the severity of the disease and influenced by the occupation and educational level of the patients. Multidisciplinary management of primary open-angle glaucoma patients is recommended.

Beyond intraocular pressure: Optimizing patient-reported outcomes in glaucoma

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.

Measuring Disability in Glaucoma

BACKGROUND

Glaucomatous visual field loss can have far-reaching and debilitating consequences on an individual, affecting one's ability to perform many important tasks. Although assessment of glaucoma-related disability constitutes an important part of clinical care, there remains a lack of organized, detailed information on the most suitable methods to capture disability in glaucoma.

PURPOSE

This review details the available methods to measure glaucoma-related disability and highlights important findings from studies utilizing these various methods.

METHODS

The literature was reviewed to identify papers evaluating disability in glaucoma and findings were summarized by research methodology used and area of impairment.

RESULTS

Identified methods for capturing glaucoma-related disability included qualitative descriptions, glaucoma-specific quality of life questionnaires, vision-specific questionnaires, general health questionnaires, functional domain-specific questionnaires, evaluation of task performance, event assessment (ie, falls and motor vehicle accidents), and real-world behavior (ie, daily physical activity). Findings using these methods show a strong relationship between glaucoma and/or glaucoma severity and difficulties with reading, driving, mobility, and other tasks such as prehension and facial recognition. In addition, glaucoma has financial and psychological implications on the patient, and can affect caregivers in some cases as well.

CONCLUSIONS

A wide variety of research tools have been used to characterize the disability resulting from glaucoma. Together, these tools show that glaucoma affects many abilities which are important for independent living. Strengths and limitations of the various research techniques are discussed so that future studies may use the method(s) most suitable for answering the research question posed.

Management Of Glaucoma In Developing Countries: Challenges And Opportunities For Improvement

Glaucoma is the leading cause of blindness in the developed and developing world. Not only is the clinical impact of this disease considerable, but associated economic and humanistic burdens - affecting patients, caregivers, and society - are substantial. Since glaucoma is an age-related disorder and populations in many developing countries are aging at a faster pace than in the developed world, increasing attention is being focused on ways to ameliorate the burdens of illness. In this paper, we examine the burdens of glaucoma with particular focus on developing countries, discuss some of the challenges that exist in delivering optimal glaucoma management within budget constraints, and bring into perspective how we could improve current healthcare systems, leverage technology, and strike an appropriate balance between cost and quality of care, thereby offering considerations to payors and policymakers in these countries that may result in longer-term cost savings, while concurrently striving to achieve the WHO Vision on the prevention of blindness and visual impairment.

Glaucoma-Associated Visual Task Performance and Vision-Related Quality of Life in South India

OBJECTIVE/PURPOSE

Performance-based measures may provide an objective assessment of how glaucoma affects daily functioning. We sought to validate a clinically-applicable performance-based measure of visual ability for patients with glaucoma in south India and to describe its relationship to clinical and patient-reported outcomes.

DESIGN

Cross-sectional validation study.

SUBJECTS/PARTICIPANTS/CONTROLS

145 participants with glaucoma were recruited at Aravind Eye Hospital.

METHODS/INTERVENTION/TESTING

We modified the compressed assessment of activities related to vision (CAARV), a performance-based measure validated in the U.S., to be culturally relevant in south India. Participants underwent a series of tests, including the Indian CAARV (I-CAARV), Indian Visual Functioning Questionnaire (IND-VFQ), Spaeth/Richman Contrast Sensitivity (SPARCS) test, standard automated perimetry, and visual acuity (VA). Factor analysis and Rasch modeling were used to validate the I-CAARV. Correlations between the I-CAARV and other outcomes were evaluated.

MAIN OUTCOME MEASURE

Psychometric properties of the I-CAARV for individuals with glaucoma in south India.

RESULTS

The study included 142 participants (51.7% female, mean age 56.4 years). Average presenting visual acuity and visual field mean deviation (MD) in the better-seeing eye were 0.26 logMAR and -6.57 dB, respectively. The four tasks of the I-CAARV were found to measure a single underlying construct. Rasch analysis of the I-CAARV revealed that the outcome measure had moderate reliability, good construct and content validity, and fair measurement precision. Tasks were well-targeted to the study sample. Rasch-calibrated scores on the I-CAARV were significantly correlated with Rasch-calibrated IND-VFQ scores (r=-0.54) and with visual field MD, presenting VA, best-corrected VA, and SPARCS contrast sensitivity in both the better-seeing eye (r=0.60, -0.51, -0.53, 0.76, respectively) and worse-seeing eye (r=0.48, -0.61, -0.46, 0.69, respectively).

CONCLUSIONS

The I-CAARV is a valid performance-based measure of vision-dependent functioning in glaucoma in south India. This study also found that I-CAARV task performance was strongly correlated with contrast sensitivity and suggests that performance-based and patient-reported outcomes are related but distinct measures of the impact of glaucoma on functioning and vision-related quality of life. Future studies are needed to determine the sensitivity of the I-CAARV to detect changes due to disease progression that are relevant to functioning and vision-related quality of life.

Combined machine learning and diffusion tensor imaging reveals altered anatomic fiber connectivity of the brain in primary open-angle glaucoma

Parameters derived from diffusion tensor imaging (DTI) have been found to be significantly altered in the optic tracts, optic nerves, and optic radiations in patients with primary open-angle glaucoma (POAG). In this study, DTI-derived parameters were further constructed into fiber connectivity, and we investigated anatomical fiber connectivity changes within and beyond the visual pathway in POAG patients. DTI and T1-weighted magnetic resonance images were acquired in 18 POAG patients and 26 healthy controls (HC). White matter tracts based on the Brodmann atlases (BA) were constructed using the deterministic fiber tracking method. The mean fractional anisotropy (FA), fiber number (FN), and mean fiber length (FL) were measured and then evaluated using two-sample t-tests between POAG and HC. The fiber connectivity between regions was taken as the features for classifying HC and POAG using a machine learning method known as naïve Bayesian classification. The mean FA decreased in connections between visual cortex BA17/BA18 and cortex BA23/BA25/BA35/BA36, while it increased in the connections between cortex BA3/BA7/BA9 and BA5/BA6/BA45/BA25 in POAG. Classification using fibers where a significant difference in FN had been identified produced better accuracy (ACC = 0.89) than using FA or FL (ACC = 0.77 and 0.75, respectively). The FN of individual fiber connections with higher accuracy and significant changes in POAG involved brain regions associated with vision (BA19), depression (BA10/BA46/BA25), and memory (BA29). These findings strengthen the hypothesis that POAG involves changes in anatomical connectivity within and beyond the visual pathway. Classification using the machine learning method reveals that mean FN has the potential to be used as a biomarker for detecting white matter microstructure changes in POAG.

A Novel Approach to Helping People with Glaucoma Use Their Drops Routinely

Pharmacy data reveal that 70% of patients were missing one or more days worth of drops out of five. Adopting approaches to behavior change and management skills used for people with diabetes may provide insight to improve self-management of glaucoma. Every person who is diagnosed with a chronic health condition such as glaucoma has unique life circumstances that may present barriers to behavior change. An accurate diagnosis and a treatment plan are useless if patients do not use their prescribed eye drops. Active listening and effective communication can result in persons who are more engaged in their self-care behaviors. Collaborative communication using person-centered and strengths-based messages could help eye care providers identify challenges and concerns for people with glaucoma who are experiencing inconsistencies with their eye drops. In an atmosphere where patients can discuss their challenges with treatment recommendations without judgment or fear, they are more likely to trust their provider and therefore share their situation openly and honestly. This is accomplished by choosing language that communicates mutually-agreed-upon self-management goals and addresses and strengthens individual and clinical outcomes. The eye care professional is then seen by the patient as a resource who can empathize when setbacks occur and reinforce the patient's self-management goals. Open-ended questions and tell-ask-tell approaches for identifying barriers to care are keys to more effective communication and trusting relationships. This includes recognizing that glaucoma is associated with increased rates of anxiety or depression that may be an overlooked barrier to self-management. By adopting language recommendations from diabetes care and education, eye care practitioners may be better equipped to help people with glaucoma improve their self-care.

Altered functional connectivity density in primary angle-closure glaucoma patients at resting-state

Background

Primary angle-closure glaucoma (PACG) is a neurodegenerative disease. Previous structural and functional studies of functional magnetic resonance imaging (fMRI) have demonstrated widespread dysfunction of spontaneous activity in the PACG brain. In this study, we applied a data-driven graph theory approach of functional connectivity density (FCD) mapping to investigate the altered local and global functional connectivity (FC) of the cortex in PACG.

Methods

Forty-five PACG patients (53.28±10.79 years, 17 males/28 females) and 46 well-matched healthy controls (HCs) (52.67±11.01 years,18 males/28 females) received resting-state fMRI scans. All PACG patients finished complete ophthalmologic examinations, including retinal nerve fiber layer thickness (RNFLT), intraocular pressure (IOP), average cup to disc ratio (A-C/D), and vertical cup to disc ratio (V-C/D). We calculated the between-group FCD difference for short-range and long-range in each voxel. Then, we generated the intrinsic FC of the seed region with the whole brain. Finally, correlations were investigated between FCD value of the altered regions and clinical variables.

Results

PACG patients showed increased short-range FCD in the left inferior frontal gyrus (IFG)/insula/parahippocampal gyrus and right IFG/insula (P<0.05, corrected), compared with the HCs. Simultaneously, the decreased regions in short-range FCD map were the occipital/cuneus/precuneus/superior parietal/postcentral lobe (P<0.05, corrected). In the PACG groups, decreased long-range FCD was observed in the left middle frontal gyrus compared to the HC (P<0.05, corrected). RNFLT was positively correlated with decreased short-range FCD value of the occipital/cuneus/precuneus/superior parietal/postcentral lobes, and the A-C/D was negatively correlated with the increased short-range FCD value of the left IFG/insula/parahippocampal gyrus, and the right IFG/insula.

Conclusions

Our findings suggest that PACG can induce extensive brain dysfunction, and showed different spatial distribution in short- and long-range FCD.

Subcortical visual pathway may be a new way for early diagnosis of glaucoma

Glaucoma is the leading cause of irreversible blindness worldwide, which is now viewed as a disease of brain with pathogenesis not fully understood. The main diagnostic methods are examining the retinal nerve fiber layer through optical coherence tomography and investigating visual field defect, but these methods present disadvantages in clinical practice. Studies have shown that patients with glaucoma often suffer negative emotion like anxiety and depression which is related to abnormal or reduced amygdala. Moreover, selective reduction of fMRI responses to transient achromatic stimuli in the superficial layer of the superior colliculus was found in the early glaucoma patients. By summarizing previous studies, we developed a hypothesis: superior colliculus-pulvinar-amygdala subcortical visual pathway may be involved in the incidence or progression of glaucoma. Validating this hypothesis would further clarify the mechanism of glaucoma and lead to the development of a more sensitive method for making an early diagnosis of glaucoma.

Association between glaucomatous optic disc and depressive symptoms independent of light exposure profiles: a cross-sectional study of the HEIJO-KYO cohort

BACKGROUND

Glaucoma may cause physiological and behavioural circadian misalignment because of the loss of intrinsically photosensitive retinal ganglion cells, the primary receptors of environmental light. Although studies have suggested a high prevalence of depression in patients with glaucoma, it is unclear whether the association is independent of the light exposure profiles as an important confounding factor.

METHODS

In this cross-sectional study of a community-based cohort of 770 elderly individuals (mean age, 70.9 years), glaucomatous optic discs were assessed using fundus photographs and depressive symptoms were assessed using the short version of the Geriatric Depression Scale (GDS). Daytime and night-time ambient light exposures were objectively measured for 2 days.

RESULTS

Depressive symptoms (GDS score ≥6) were observed in 114 participants (prevalence, 14.8%) and glaucomatous optic discs were detected in 40 participants (prevalence, 5.2%). The prevalence of depressive symptoms was significantly higher in the group with glaucomatous optic disc than in the group without it (30.0% vs 14.0%, respectively; p=0.005). Multivariable logistic regression analysis adjusted for potential confounding factors, including daytime and night-time light exposures, revealed that the OR for depressive symptoms was significantly higher in the group with glaucomatous optic disc than in the group without it (OR 2.45, 95% CI 1.18 to 5.08; p=0.016).

CONCLUSIONS

In this general elderly population, glaucomatous optic disc was significantly associated with higher prevalence of depressive symptoms independent of a number of potential confounding factors, including daily light exposure profiles.

Self-rated depression and eye diseases: The Beijing Eye Study

Purpose

To assess the prevalence of depression in the general population of Beijing and its association with ocular diseases.

Methods

The population-based Beijing Eye Study was conducted in a rural and an urban region of Greater Beijing. The study participants underwent a detailed ophthalmological examination and an interview including questions on the socioeconomic background. Depressive symptoms were evaluated using a Chinese depression scale adapted from Zung´s self-rated depression scale. The total score of depression symptoms was 80. Depression was defined as having a depression score >44.

Results

Out of 3468 study participants, 3267 (94.2%) individuals (1419 men) with an age of 64.5±9.7 years (range: 50–93 years) participated in the interview and answered all questions on depression. The mean depression score was 25.0±5.9 (median: 23.3; range:20–64). Depression (depression score >44) was present in 66 individuals (2.0%; 95% confidence interval (CI): 1.5, 2.5), and 5 individuals (0.2%; 95%CI: 0.02,0.3) had a depression score ≥59. In multivariate regression, analysis, a higher depression score was associated (regression coefficient r²: 0.22) with a higher number of days with dry eye feeling (P<0.001; standardized regression coefficient beta: 0.09; non-standardized regression coefficient B: 0.20; 95%CI: 0.12,0.29) and shorter corneal curvature radius (P = 0.03;beta:-0.04; B:1.01; 95%CI: -1.90,-0.12), after adjusting for age, gender, region of habitation, body mass index, cognitive function score, life quality score and blood concentration of triglycerides. Adding age-related macular degeneration (P = 0.10), glaucoma (P = 0.77), diabetic retinopathy (P = 0.77), nuclear cataract (P = 0.35), cortical cataract (P = 0.58) or posterior subcapsular cataract (P = 0.28) as single parameters to the model revealed no significant correlation with the depression score. Lower best corrected visual acuity showed a marginal significant association (P = 0.05; beta: 0.04; B: 1.56; 95%CI: -0.01, 3.13).

Conclusions

Dry eye feeling was the only common ocular disorder associated with an increased depression score, while the occurrence of age-related macular degeneration, any type of glaucoma, diabetic retinopathy, any type of cataract and keratoconus were not significantly associated with an increased depression score. Lower visual acuity was marginally associated. The prevalence of depression in the population aged 50+ years in Greater Beijing was 2.0% (96%CI: 1.5, 2.5).