Risk factors for depressive symptoms in glaucoma patients: a nationwide case-control study

Depression and Eye Disease-A Narrative Review of Common Underlying Pathophysiological Mechanisms and their Potential Applications

Background: Depression has been shown to be associated with eye diseases, including dry eye disease (DED), cataracts, glaucoma, age-related macular degeneration (AMD), and diabetic retinopathy (DR). This narrative review explores potential pathophysiological connections between depression and eye disease, as well as its potential correlations with ocular parameters. Methods: A literature search was conducted in August 2022 in PUBMED, EMBASE, and PsycINFO. Published articles related to the subject were consolidated and classified according to respective eye diseases and pathophysiological mechanisms. Results: The literature reviewed suggests that common pathophysiological states like inflammation and neurodegeneration may contribute to both depression and certain eye diseases, while somatic symptoms and altered physiology, such as disruptions in circadian rhythm due to eye diseases, can also influence patients' mood states. Grounded in the shared embryological, anatomical, and physiological features between the eye and the brain, depression is also correlated to changes observed in non-invasive ophthalmological imaging modalities, such as changes in the retinal nerve fibre layer and retinal microvasculature. Conclusions: There is substantial evidence of a close association between depression and eye diseases. Understanding the underlying concepts can inform further research on treatment options and monitoring of depression based on ocular parameters.

Endocannabinoids and cortisol in plasma, aqueous and tear samples of primary angle closure glaucoma versus controls

PURPOSE

To compare the levels of endocannabinoids (EC) in plasma, aqueous humor and tears, cortisol in plasma and aqueous, in primary angle closure glaucoma (PACG) and controls, while comparing the quality of life in both groups.

METHODS

A total of 60 patients, ≥40years of age, with a diagnosis of PACG or cataract, 30 in each group were recruited. They were subjected to a detailed ophthalmic evaluation, a WHO Quality of Life Brief Version (WHOQOL-BREF) questionnaire answering and collection of tear, aqueous and blood samples. The levels of endocannabinoids-anandamide (AEA), 2-arachidonoylglycerol (2AG) in plasma, aqueous humor and tears; cortisol in plasma and aqueous humor; and WHO-QOL score in each group were noted.

RESULTS

Plasma AEA (p = 0.01) and plasma 2-AG, (p = 0.002) levels were significantly higher in the control group as compared to the PACG group. WHO-QOL score was better in controls (p < 0.001). The EC were in undetectable levels in aqueous. Plasma and aqueous cortisol were significantly higher in PACG and both had the highest Area under the receiver operating characteristics (AUROC) curve value for differentiating PACG from controls. Tear 2AG and tear AEA had a moderately strong positive correlation with plasma 2-AG. Females had insignificantly higher levels of plasma and tear endocannabinoids.

CONCLUSIONS

Tear endocannabinoids were determined for the first time in PACG and normal with no difference between the two groups. Plasma and aqueous cortisol levels are a differentiating factor between normal and glaucoma patients with plasma endocannabinoids being remarkably higher in normals. Quality of life in glaucoma patients with high cortisol levels is poorer.

R., Janana Priya G.. Association of Visual Impairment with Suicidal Ideation and Suicide Attempts: A Systematic Review and Meta-Analysis

Background

Worldwide, there is an increase in the incidence of suicide each year. Suicide attempts are estimated to be more frequent than actual suicide mortality. One potential contributor to suicide risk is the presence of sensory impairments (visual or hearing impairments). The present review aimed to assess the direction and strength of the association between visual impairment (VI) and the risk of suicidal behavior.

Methods

A systematic search was carried out on the literature published up to July 2021 in PubMed, Embase, Cochrane Library, and clinicaltrials.gov. The association between VI and suicidal ideation/attempt was summarized by pooled odds ratio with 95% CI.

Results

Six studies with a sample size of 1,64,752 were included in the final quantitative synthesis. The pooled odds ratios (95% CI) for suicidal ideation and attempt among persons with VI were 1.53 (1.30-1.79) and 4.55 (2.39-8.67), respectively. On subgroup analysis, the odds of suicidal ideation were higher in persons with additional sensory impairment, 2.07 (1.21-3.53), than in the group with VI only, 1.63 (95% 1.34-1.98).

Conclusion

This study found a significant association between suicidal behavior and VI, more so in persons with dual impairment. Structured assessment for psychological health and appropriate management should be an integral part of managing people with visual and other sensory impairments, to prevent this serious adverse consequence.

Improving health-related quality of life in glaucoma during 11 years and its association with vision loss and treatment of the disease

PURPOSE

To evaluate the impact of glaucoma on health-related quality of life (HRQoL) and mental health in the ageing population of Finland.

METHODS

Altogether 7380 and 5774 Finnish individuals aged 30 years and older with known eye disease status were studied in 2000 and 2011, respectively, in two population-based surveys, including an 11-year follow-up of 4683 participants. Data on HRQoL (EQ-5D-3L, 15D), depression (BDI), psychological distress (GHQ-12) and eye disease diagnoses were obtained from self-reported assessments. Information on glaucoma was complemented with the medication, diagnosis and eye surgery data obtained from the Finnish Health Registries. Distance visual acuity was assessed using the Snellen eye chart test. In logistic regression analyses, data were corrected for age, gender and the most common comorbidities.

RESULTS

Glaucoma patients with verified diagnosis (n = 192 in 2000, n = 202 in 2011) and individuals with self-suspected glaucoma (n = 100 in 2000, n = 41 in 2011) showed a significant decrease in their HRQoL. Glaucoma was also associated with worsened overall mental health based on BDI and GHQ-12 results. Visual impairment associated with glaucoma is the major determinant of the reduced HRQoL and mental health. Neither glaucoma medication nor glaucoma surgery affected these parameters. The impact of glaucoma on HRQoL and mental health diminished between 2000 and 2011 in a cross-sectional setting. The newly diagnosed glaucoma during the 11-year follow-up had a minimal effect on them.

CONCLUSION

Glaucoma patients show reduced HRQoL and mental health, which is associated with vision loss regardless of the awareness or treatment of the disease. However, this effect seems to be diminishing over time, and the newly diagnosed glaucoma did not show a significant effect on either HRQoL or mental health.

Depression in glaucoma patients: A review of the literature

Purpose: The purpose of this review was to evaluate the association between glaucoma and depression and to identify possible risk factors for depressive symptoms in glaucoma patients.Methods: A total of 587 abstracts were screened and 32 studies were deemed eligible for inclusion in this review.Results: An association of glaucoma and depression was found, while advanced disease stage, older age, female sex and faster visual loss progression were recognized as potential risk factors for depression in patients with glaucoma.Conclusions: Our findings may have important clinical significance, such as alerting ophthalmologists to implement a multidisciplinary approach in patients with glaucoma. Further research is needed to examine this association in different types of glaucoma and try to investigate the underlying pathophysiological mechanisms to establish a causal inference between glaucoma and depression.

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.

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.

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.

Prevalence of depression and anxiety among participants with glaucoma in a population-based cohort study: The Gutenberg Health Study

Background

To investigate the prevalence of depression and anxiety among subjects with self-reported glaucoma and the association between self-reported glaucoma and depression respectively anxiety in a European cohort.

Methods

A study sample of 14,657 participants aged 35 to 74 years was investigated in a population-based cohort study. All participants reported presence or absence of glaucoma. Ophthalmological examinations were carried out in all participants and demographic and disease related information were obtained by interview. Depression was assessed with the Patient Health Questionnaire (PHQ-9), and generalized anxiety with the two screening items (GAD-2) of the short form of the GAD-7 (Generalized Anxiety Disorder-7 Scale). Prevalence of depression and generalized anxiety were investigated for subjects with and without self-reported glaucoma. Logistic regression analyses with depression, respectively anxiety as dependent variable and self-reported glaucoma as independent variable were conducted and adjusted for socio-demographic factors, systemic comorbidities (arterial hypertension, myocardial infarction, stroke, diabetes mellitus, chronic obstructive pulmonary disease, cancer), ocular diseases (cataract, macular degeneration, corneal diseases, diabetic retinopathy), visual acuity, intraocular pressure, antiglaucoma eye drops (sympathomimetics, parasympathomimetics, carbonic anhydrase inhibitors, beta-blockers, prostaglandins) and general health status.

Results

293 participants (49.5% female) reported having glaucoma. Prevalence of depression among participants with and without self-reported glaucoma was 6.6% (95%-CI 4.1–10.3) respectively 7.7% (95%-CI 7.3–8.2), and for anxiety 5.3% (95%-CI 3.1–8.7) respectively 6.6% (95%-CI 6.2–7.1). Glaucoma was not associated with depression (Odds ratio 1.10, 95%-CI 0.50–2.38, p = 0.80) or anxiety (1.48, 95%-CI 0.63–3.30, p = 0.35) after adjustment for socio-demographic factors, ocular/systemic diseases, ocular parameters, antiglaucoma drugs and general health status. A restriction to self-reported glaucoma cases either taking topical antiglaucoma medications or having a history of glaucoma surgery did not alter the result.

Conclusions

This is the first study analyzing both depression and anxiety among glaucoma patients in a European cohort. Subjects with and without self-reported glaucoma had a similar prevalence of depression and anxiety in our population-based sample. Self-reported glaucoma was not associated with depression or anxiety. A lack of a burden of depressive symptoms may result from recruitment from a population-based sample as compared to previous study groups predominantly recruited from tertiary care hospitals.

The association between glaucoma and risk of depression: a nationwide population-based cohort study

Background

Previous cross-sectional studies revealed a higher prevalence of depression among glaucoma patients. However, cohort studies were in lack to build the risk of incident depression after the diagnosis of glaucoma. The aim of our study was to investigate the association between glaucoma and the subsequent risk of developing depression and to assess risk factors associated with depression in glaucoma patients.

Methods

A population-based retrospective cohort study using the Taiwan National Health Insurance Research Database was conducted from January 1, 2001 through December 31, 2011. Glaucoma patients (n = 8777) and age- and gender-matched control subjects without glaucoma (n = 35,108) were enrolled in the study. Kaplan-Meier curves were generated to compare the cumulative hazard of subsequent depression between the glaucoma and control groups. A Cox regression analysis estimated the crude and adjusted hazard ratios (HRs) for depression. Risk factors leading to depression were investigated among the glaucoma patients.

Results

Glaucoma patients had a significantly higher cumulative hazard of depression compared to the control group (p-value < 0.0001). The Cox regression model indicated that the glaucoma group had a significantly higher risk of depression (adjusted HR = 1.71). Within the glaucoma group, significant risk factors for depression included age, female, low income, substance abuse, and living alone. However, the use of β-blocker eye drops and the number of glaucoma medications were not significant risk factors for depression.

Conclusion

Patients with glaucoma are at significantly greater risk of developing depression. Among glaucoma patients, age, female, low income, substance abuse, and living alone were significant risk factors for depression.

Depressive symptoms in older adults awaiting cataract surgery

BACKGROUND

To assess the prevalence and predictors of depressive symptoms in a cohort of older adults awaiting cataract surgery and establish threshold vision at which depressive symptoms may emerge.

DESIGN

Analysis of cross-sectional baseline data from a longitudinal cohort study of patients aged ≥65 years on Australian public hospital cataract surgery waiting lists.

PARTICIPANTS

We included 329 participants enrolled October 2013-August 2015.

METHODS

Participants completed assessment of depressive symptoms, visual disability, quality of life, social participation and exercise frequency at least one month prior to cataract surgery. High and low contrast habitual vision was examined and systemic comorbidities noted.

MAIN OUTCOME MEASURE

Depressive symptoms prior to first eye cataract surgery.

RESULTS

The prevalence of depressive symptoms was 28.6% (94/329). Univariate analysis identified that participants with poorer high contrast vision, reduced quality of life, greater patient-reported visual disability, higher comorbidity score and who were taking more medications were more likely to exhibit signs of depression. Greater patient-reported visual disability (P = 0.02), reduced quality of life (P = 0.003) and a higher comorbidity score (P = 0.02) remained significantly associated with depressive symptoms in the multivariable model. Depressive symptoms emerged at a visual acuity of 6/12.

CONCLUSIONS

These findings demonstrate a high prevalence of depressive symptoms in older persons with cataract, emerging at modest levels of vision loss. Efficient referral processes, timely surgical management, and improved screening and coordinated treatment of depressive symptoms during the surgical wait may minimize the negative psychological effects of cataract in this already vulnerable population.

Mental Health Status and Quality of Life in Undiagnosed Glaucoma Patients: A Nationwide Population-Based Study

Glaucoma is a leading cause of irreversible vision loss. Mental health and quality of life (QoL) are important issues for patients with glaucoma because visual impairment can be related to those. Analysis of mental health status or QoL in undiagnosed glaucoma patients can be free of the bias caused by awareness of the disease itself. In this study, the association between mental health status or QoL and undiagnosed glaucoma, along with the effects of visual acuity or visual field damage was investigated. Among individuals in the Korea National Health and Nutrition Examination Survey (KNHANES) V (2010-2012), subjects 40 years or older were included. KNHANES is a cross-sectional study using a stratified, multistage, probability sampling survey. The KNHANES includes questionnaires to assess psychological health, including depression, sleep duration, psychological stress, and suicidal ideations. To evaluate QoL, the KNHANES includes the EuroQoL, which is composed of a health-status descriptive system (EuroQol 5-dimension, EQ-5D) and the EQ visual analog scale (EQ-VAS). The proportion of people reporting symptoms of "some or severe problems" in all 5 dimensions of the EuroQoL-5 instrument, including anxiety/depression, was higher in the glaucoma group than in the nonglaucoma group. The subjective health status reported by the EQ-VAS was lower in the subjects with glaucoma than in those without glaucoma. Suicidal ideation was greater in subjects with glaucoma than in those without glaucoma (P = 0.005). After adjustment for demographic factors, glaucoma subjects were more likely than those without glaucoma to have some or severe problems with anxiety/depression (odds ratio 1.77; 95% confidence interval, 1.26-2.49). Worse best corrected visual acuity was associated with more problems with a lower EQ-5D score in glaucoma subjects. Individuals who had undiagnosed glaucoma were more depressed than those without glaucoma. QoL can be affected by glaucoma, especially in patients with worse visual acuity.

Fast Visual Field Progression Is Associated with Depressive Symptoms in Patients with Glaucoma

PURPOSE

To evaluate the association between the rates of progressive visual field loss and the occurrence of depressive symptoms in patients with glaucoma followed over time.

DESIGN

Prospective observational cohort study.

PARTICIPANTS

The study included 204 eyes of 102 patients with glaucomatous visual field defects on standard automated perimetry (SAP).

METHODS

All patients had Geriatric Depression Scale (GDS) questionnaires and visual field tests obtained over a mean follow-up time of 2.2±0.6 years. Change in depressive symptoms was assessed by calculating the difference between GDS scores at the last follow-up visit from those at baseline. Rates of visual field loss were assessed by SAP. An integrated binocular visual field was estimated from the monocular SAP tests, and rates of change in mean sensitivity (MS) over time were obtained from linear mixed models. Regression models were used to investigate the association between progressive visual field loss and changes in depressive symptoms, adjusting for potentially confounding clinical and socioeconomic variables.

MAIN OUTCOME MEASURES

The association between rates of change in binocular SAP MS and change in GDS questionnaire scores.

RESULTS

There was a significant correlation between change in the GDS scores during follow-up and change in binocular SAP sensitivity. Each 1 decibel (dB)/year change in binocular SAP MS was associated with a change of 2.0 units in the GDS scores during the follow-up period (P = 0.025). In a multivariable model adjusting for baseline disease severity, change in visual acuity, age, gender, race, Montreal Cognitive Assessment score, education, income, and comorbidity index, each 1 dB/year change in binocular SAP MS was associated with a change of 3.0 units in the GDS score (P = 0.019).

CONCLUSIONS

Faster visual field progression was associated with the occurrence of depressive symptoms in patients with glaucoma.