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Dr.Ashutosh Dayal,Dr.Kalyani Vijaya Kumari,Dr.Vidya Chelerkar,Dr.(col) Madan Deshpande

ABSTRACT

OBJECTIVES:

To assess the impact of Glaucoma and associated visual field defects on psychosocial functions and Quality of life.

METHODS

A cross sectional study was carried on 100 patients attending Glaucoma clinic of a tertiary care hospital.All patients underwent a thorough ophthalmic examination.Those with primary glaucoma were asked to respond to National Eye Institute Visual Function Questionnaire(NEIVFQ)-25and Hospital Anxiety and Depression scale(HADS)questionnaire and responses analyzed.

RESULTS- Overall mean NEIVFQ25 composite score was 72.6 ±18.3. Mean scores were 85.1 ±8.2for mild,74.3 ±8.9for moderate and 47.6 ±16.2for severe glaucoma(p <0.001). Lower scores were associated with males and treatment duration(p<0.05).39 patients had anxiety or depression on HADS scale.

CONCLUSION

Glaucoma affects psychosocial function of patients causing dependency, depression, leading to treatment noncompliance and impaired quality of life. Psychological assessment and counselling should be included in management

INTRODUCTION

Glaucoma is a chronic progressive optic nerve disease that can lead to visual field loss and blindness if left untreated. It is characterized by progressive retinal ganglion cell layer loss leading to visual field defects. The diagnosis of glaucoma is often delayed as the disease characteristically involves peripheral and mid peripheral fields. Hence the disease progression is silent and asymptomatic in early stages. Unfortunately, at the time of first presentation, many patients have significant peripheral visual field defect. This is truer for developing country like India.

Primary glaucoma is one of the leading cause of irreversible blindness worldwide, affecting 60 million people globally and 12 million people in India alone.[1][2]Its asymptomatic chronic nature, lifelong treatment and potential outcome of blindness imposes a greater psychological burden on the patients. Treatment of glaucoma is primarily based upon retarding the progression of disease by control of intraocular pressure. This is achieved primarily by lifelong medications or sometimes surgery.

WHO defines quality of life as individual’s perspective of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.[3]Glaucoma can impair Quality of Life of a patient primarily due to visual disability and psychosocial factors associated with the disease. Visual disability occurs as a result of ganglion cell loss resulting in progressive visual field loss that hampers daily activities such as reading or driving and thus limiting social functioning. Psychological factors including diagnosis of potentially blinding condition can produce anxiety and depression in the patients, even in early stages.[4]In addition, factors such as side effect of medication, lifelong treatment, regular follow ups and cost of treatment can lead to further aggravate the problem and may lead to demotivation and treatment noncompliance.

Various tools are available for measuring the Quality of Life which can be either generic, such as sickness profile (SIP), SF-36, or Vision specific or Glaucoma specific questionnaires. Studies have shown vision and glaucoma specific questionnaires to be more significantly corelating with visual field defects, although there is no gold standard as yet.

National Eye Institute Visual Function Questionnaire (NEIVFQ-25) is a vision specific, 25 item self-administered questionnaire that measures 12 quality of life related sub scales including general health status. Each question has minimum score is 0 and maximum is100. Average of the 11-vision related Quality of life subscales gives composite score. It assesses patient’s perception of both- visual function and quality of life.[5]One of the advantages of NEIVFQ 25 over glaucoma specific questionnaires is that it measures general health status of the patient also, and hence has been widely utilized in various studies.

Hospital Anxiety and depression scale (HADS) consists of 2 set of questions, one measuring Anxiety (HADS-A) and the other measuring Depression (HADS-D).[6]

MATERIAL AND METHODOLGY:

A cross sectional study was conducted at a tertiary care eye hospital. Patients attending the Glaucoma clinic of the hospital were explained in detail about the study and the procedure. Informed written consent was obtained from those patients who were willing to participate. A detailed history including family history was obtained.  Patients underwent a thorough clinical examination which included Snellen visual acuity, tonometry by Goldman Applanation tonometer, slit lamp examination, gonioscopy, pachymetry, perimetry by Humphrey’s 24-2 field analyser and dilated fundus evaluation.Humphrey’s 10-2 was used for patients with very advanced glaucomatous defects threatening the macula.

Patients with primary glaucoma were included as per the inclusion criteria. Those with secondary glaucoma or any other ocular comorbidity causing significant impairment in vision such as Diabetic macular edema, Age related Macular degeneration etc and those below 20 years of ageat the time of diagnosis were excluded.Patients were categorized as mild, moderate and severe on Humphrey’s field analyser by using Hodapp Parrish Anderson criteria. Perimetry of the better or less involved eye was considered for this classification.

Participants were also grouped upon duration of treatment as those on treatment for less than one year, those on treatment for more than one year but less than 3 years and those on treatment for three or more years.

Patients were explained the NEIVFQ-25 and HADS questionnaires and were asked to respond to it. For patients having difficulty in reading, a trained health personal was allotted to read out the questionnaire for them.Scoring was done on the basis of the recommended algorithm provided with manual for the corresponding questionnaires. Responses were analysed statistically using Microsoft Excel 2013 and SPSS 11.0.

RESULTS:

A total of 100 patients participated in the study. Mean age of participants was 61.4 years (SD 11.7) with age range varying from 23 years to 82 years. Out of 100, 59 were males whereas 41 participants were females. 77 participants had primary open angle glaucoma while 23 had primary angle closure glaucoma. 29 participants had either trabeculectomy or glaucoma drainage device implantation done in at least one of the eyes previously. (Figure 1)

The mean NEIVFQ 25 composite score was 72.6(SD 18.3). Mean mental health score was 67.99 (SD 22.4). Mental health scores and vision specific role difficulties were most affected while social functioning and colour vision scores were least affected. Mean HADS-Anxiety score was 5.12 and mean HADS- Depression score was 5.38. Mean composite score for females (78.53) was found to be higher than males (68.52). (p<0.05).

On the basis Hodapp Parrish Anderson criteria, 44 participants were categorized as mild, 32 had moderate field changes while 24 had advanced disease. Mean NEIVFQ score for mild cases was 85.07 (SD 8.2), for moderate cases was 74.29(SD 8.90) and for advanced cases was 47.5 (SD 16.2). (p<0.001). Mental health sub scores for mild disease was 80.59 (SD 12.47), for moderate were 70.85 (SD 18.80) and for advanced disease were 41.06 (SD 18.20). (p<0.001).

Figure 1: NEIVFQ 25 composite and mental health scores in mild, moderate and advanced disease

Patients with duration of treatment for less than 1 year had better scores 79.82 (SD 7.41) than those with disease duration for more than 1 year but less than 3 years 74.13 (8.91) and those with duration more than 3 years 66.71(SD 11.20). (p<0.05).

No statistically significant difference was found in the mental health sub scores and duration of disease.

DISCUSSION:

Glaucoma is currently the second leading cause of blindness worldwide.[7][8] It is a chronic disease causing gradual visual field impairment and thereby directly affecting the daily activities of the patient. Due to the potentially blinding nature of the disease, there has been a social stigma attached to it. This results in an emotional or psychological setback to many patients on learning the diagnosis. Although the disease progression can be retarded by the use of intraocular pressure lowering drugs, the lifelong treatment,adverse effect of polypharmacy and financial burden can add to the patient woes. All the above factors can lead to lower self-esteem, dependency and noncompliance to treatment, which may further deteriorate the visual function.

Due to these reasons, various studies have been undertaken in the recent years to measure the impact of glaucoma and its treatment on quality of life of patients. These would provide an estimate on the magnitude of psychosocial impairment of the patient as well as aid in customizing treatment options. NEIVFQ 25 is one such tool that aids in measuring the psychosocial functioning and quality of life quantitatively. It provides us with the scores of 12 vision related aspects pertaining to quality of life. The average of 11 of these scores gives an overall composite score. Maximum score for each subscale is 100 while minimum is zero.

Our study demonstrated comparatively lower NEIVFQ comprehensive score of  72.6 for glaucoma patients. This may be attributed to impact of the disease on psychology as well as various day to day activities. Driving and vision related role difficulty were most affected while colour vision and social functioning was least affected. This may be attributed to the fact that the latter two functions are affected only when there are advanced field defects threatening to impair the central vision, as seen in advanced disease. Studies done previously had similar findings.[9]

In our study, 44% participants had mild glaucoma on perimetry, 32% had moderate glaucoma while 24% had advanced disease. This demographic distribution was comparable with similar studies done in the past.[10][11]There was a significant deterioration in the mean NEIVFQ scores amongst mild, moderate and advanced glaucoma (p<0.001). This confirms the fact that as the visual field defects progress, more and more daily routine and social functions get hampered, that in turn impairs quality of life of patients. NEIVFQ 25 scores were also affected by duration of disease.

Quality of life may also be influenced by factors other than visual impairment such as lifelong treatment, adverse effect of medications, financial burden as well. This is illustrated by the fact that patients with disease duration for less than 1 year had better scores than those with duration more than 1 year but less than 3 years and those with more than 3 years.Similar findings were reported by a previous study just after 3 months of starting topical treatment for glaucoma.[12]

Comprehension of glaucoma plays a vital part in patient psychological thought process which may in turn affect the compliance and quality of life. Sometimes even just knowing the diagnosis of potentially blinding disease can cause depression or anxiety. Also, non-curable nature of the disease with visual impairment may lead to frustration in some. Role of disease comprehension and its effect on glaucoma was mentioned in studies done previously in various countries.[13][14][15] In our study, we found that mental health subscale function was impaired early in the disease. It was negatively affected effected with severity of glaucoma. Advanced glaucoma patients had the worst scores on NEIVFQ25. However, we couldn’t find any correlations between the duration of treatment and mental health scores. Therefore, it is mandatory for health care providers to counsel and motivate the patient right at the time of diagnosis as well as periodically during the course of treatment.

CONCLUSION:

Glaucoma causes impairment of psychosocial functions due to long duration of treatment, lifelong follow ups, social stigmata, visual field defects and dependency in later stages. These patients may develop anxiety, depression, low self-esteemdue to impaired impairment of quality of life. These factors may lead to treatment noncompliance leading to further visual deterioration of the visual function. The above factors should be borne in mind while treating glaucoma patients.Periodic psychological assessment and motivational counselling of the patient as well as his or her attenders should be included as part of management of glaucoma.

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