Visual impairment and vision-related quality of life in the Early Manifest Glaucoma Trial after 20 years of follow-up

Mapping vision loss of patients in a glaucoma backlog following the COVID-19 pandemic: a real-world analysis using the Glauc-Strat-Fast risk stratification tool

INTRODUCTION

Glauc-Strat-Fast is a clinical tool recommended by The Royal College of Ophthalmologists to classify glaucoma patients into strata of risk for significant future sight loss and an estimate of resource requirement. The aim of this study was to map the movement of glaucoma patients across stratification boundaries on Glauc-Strat-Fast during the COVID-19 pandemic.

SUBJECTS AND METHODS

Glauc-Strat-Fast was applied to a consecutive sample of 100 primary open angle glaucoma patients in a backlog at Worcestershire Acute Hospitals NHS Trust. Stratification outcomes were compared between clinic visits prior to the COVID-19 pandemic versus the follow-up visit. Patients were stratified twice separately based on their worse eye (i.e., most affected) and better eye (i.e., least affected) according to Glauc-Strat-Fast.

RESULTS

Amount of slippage (difference between target follow-up and actual follow-up) ranged from 2 to 32 months. There was a statistically significant average reduction in visual field mean deviation for better and worse eyes between visits (p = <0.001). At follow-up, no worse eyes were classified as being low risk (green), while 96 were classified as high risk (red). For better eyes, elevation of risk into the highest strata of Glauc-Strat-Fast observed a three-fold increase in patients (19 versus 56) between visits.

DISCUSSION

This retrospective real-world analysis highlights patients' movement into the highest strata on the Glauc-Strat-Fast tool and demonstrates a significant deterioration in visual outcomes during a period of extensive appointment slippage. The findings demonstrate the utility of Glauc-Strat-Fast as a tool for improved patient management.

Vision-related quality of life among 70-year-olds diagnosed with glaucoma

PURPOSE

To evaluate the effect of glaucoma on vision-related quality of life (VRQoL), lifestyle, physical factors and socioeconomic status in a 70-year-old population in Gothenburg, Sweden.

METHODS

Responses to questionnaires (N = 1182) between groups with and without self-reported glaucoma were analysed. Questionnaires included National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25), Short-Form Health Survey (SF-36), physical activity, socioeconomics, alcohol and tobacco consumption. Balance test and body mass index were also included. About half of the participants were randomized to ophthalmic examination (N = 560), variables were analysed separately according to known and confirmed glaucoma, ocular hypertension and/or cases of previously unknown glaucoma.

RESULTS

Both conventional and Rasch analysis of the NEI VFQ-25 showed that VRQoL was lower for individuals self-reporting glaucoma (p = 0.003/p = 0.024). Regarding general QoL, the participants did not differ apart from people self-reporting glaucoma reported worse general health (p = 0.01). Using logistic regression with lower VRQoL as the dependent variable glaucoma was not a significant predictor of poor VRQoL, odds ratio (OR) 1.83 (95% confidence interval (CI) 0.76-4.39, p = 0.18). Low household income was associated with lower VRQoL (OR 1.63, 95% CI 1.14-2.33, p = 0.01). Socioeconomics, physical activity and lifestyle factors were comparable between the groups (N = 915). Among participants who underwent ophthalmic examination no significant differences were found between glaucoma cases and non-glaucoma cases in relation to VRQoL (N = 560).

CONCLUSIONS

Patients with self-reported glaucoma assessed a lower VRQoL but not lower general quality of life. Poorer household income was associated with worse VRQoL. General health was reported low in the glaucoma population but lifestyle or physical factors did not diverge.

Charles Bonnet Syndrome Adversely Affects Vision-Related Quality of Life in Patients with Glaucoma

PURPOSE

To investigate the impact of Charles Bonnet syndrome (CBS) on vision-related quality of life (VRQoL) in patients with glaucoma.

DESIGN

Cross-sectional cohort study.

PARTICIPANTS

Twenty-four patients with CBS and 42 matched controls without CBS out of 337 patients with open-angle glaucoma (OAG) with visual field (VF) loss.

METHODS

A matching technique was used to identify control patients with similar disease stage, best-corrected visual acuity (BCVA) and age to patients with CBS. Patients' VRQoL was determined using the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ-25). Rasch-calibrated NEI VFQ-25 scores of the CBS group and the control group were compared. Uni- and multivariable regression analysis was used to evaluate the impact of different factors on VRQoL.

MAIN OUTCOME MEASURES

Vision-related quality of life in patients with glaucoma with CBS and without CBS.

RESULTS

Vision-related quality of life scores were significantly lower in the CBS group than in the control group on both the visual functioning scale with 39 points (95% confidence interval (CI): 30-48) vs. 52 points (95% CI: 46-58) (P = 0.013) and on the socioemotional scale with 45 points (95% CI: 37-53) vs. 58 points (95% CI: 51-65) (P = 0.015). Univariable regression analysis showed that integrated visual field mean deviation (IVF-MD) (r2 = 0.334, P < 0.001), BCVA in the better eye (r2 = 0.117, P = 0.003), and the presence of CBS (r2 = 0.078, P = 0.013) were significantly correlated to VRQoL scores on the visual functioning scale. Integrated visual field mean deviation (r2 = 0.281, P < 0.001), age (r2 = 0.048, P = 0.042), and the presence of CBS (r2 = 0.076, P = 0.015) were significantly correlated to VRQoL scores on the socioemotional scale. Multivariable regression analysis showed that IVF-MD and the presence of CBS accounted for nearly 40% of the VRQoL score on the visual functioning scale (R2 = 0.393, P < 0.001) and for 34% of the VRQoL score on the socioemotional scale (R2 = 0.339, P < 0.001).

CONCLUSIONS

Charles Bonnet syndrome had a significant negative association to VRQoL in patients with glaucoma. Presence of CBS should be considered when evaluating VRQoL in patients with glaucoma.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Five-Year Visual Field Outcomes of the HORIZON Trial

PURPOSE

To compare visual field (VF) progression between glaucoma patients receiving cataract surgery alone (CS) or with a Hydrus microstent (CS-HMS).

DESIGN

Post hoc analysis of VF data from the HORIZON multicenter randomized controlled trial.

METHODS

A total of 556 patients with glaucoma and cataract were randomized 2:1 to either CS-HMS (369) or CS (187) and followed up for 5 years. VF was performed at 6 months and then every year after surgery. We analyzed data for all participants with at least 3 reliable VFs (false positives < 15%). Average between-group difference in rate of progression (RoP) was tested using a Bayesian mixed model and a 2-sided Bayesian P value <.05 (main outcome). A multivariable model measured the effect of intraocular pressure (IOP). A survival analysis compared the probability of global VF sensitivity dropping by predefined cutoffs (2.5, 3.5, 4.5, and 5.5 dB) from baseline.

RESULTS

Data from 352 eyes in the CS-HMS arm and 165 in the CS arm were analyzed (2966 VFs). The mean RoP was -0.26 dB/y (95% credible interval -0.36, -0.16) for CS-HMS and -0.49 dB/y (95% credible interval -0.63, -0.34) for CS. This difference was significant (P = .0138). The difference in IOP only explained 17% of the effect (P < .0001). Five-year survival analysis showed an increased probability of VF worsening by 5.5 dB (P = .0170), indicating a greater proportion of fast progressors in the CS arm.

CONCLUSIONS

CS-HMS has a significant effect on VF preservation in glaucoma patients compared with CS alone, reducing the proportion of fast progressors.

Assessment of quality of life in glaucoma patients in a tertiary care center in Eastern India

Purpose

The aim of this study is to assess the quality of life (QOL) in glaucoma patients and find out the sociodemographic factors predicting QOL.

Methods

A cross-sectional study was conducted in a tertiary care center from August 2021 to February 2022. Subjects diagnosed with glaucoma for at least 6 months were enrolled. After taking informed consent, demographic details and detailed history were collected for all patients. Comprehensive eye examination (visual acuity, intraocular pressure, gonioscopy, fundoscopy, visual field assessment, ocular coherence tomogram assessment) was done for all and they were asked to fill the WHOQOL-BREF questionnaire. Data were collected and analyzed using SPSS 21.

Results

One hundred and ninety-nine patients were recruited. Mean age of participants was 57.99 ± 10.76 years. Based on various domains and subgroups, QOL values were significant with respect to income (P = 0.016). Gender-wise QOL in females was lower than that of males with respect to all the domains (P = 0.001). While marital status affected both environmental and social domain, literacy affected only the social domain. A variation in intraocular pressure affected the QOL in the psychological domain. QOL was not significantly associated with the severity of the disease. Gender was the most predominant predictor out of all sociodemographic factors.

Conclusion

Chronic diseases affect the QOL of individuals in many ways. Glaucoma being a chronic disease hampers patients' vision irreversibly and by extension the various physical, social, and psychological aspects of the patient's life as well. Hence, knowledge of the change in QOL it brings about can help plan the treatment, counseling, and management of these patients.

Factors Associated with Visual Acuity in Advanced Glaucoma

This study aimed to comprehensively analyze various parameters in advanced glaucoma patients to identify the factors that can affect best-corrected visual acuity (BCVA) in advanced glaucoma. This cross-sectional retrospective study included 113 patients (mean age, 61.66 ± 13.26 years; males, 67) who had advanced glaucomatous damage (113 eyes; mean BCVA, 0.18 ± 0.38 logMAR; mean deviation of 30-2 visual field [VF], -19.08 ± 6.23 dB). Peripapillary retinal nerve fiber layer (RNFL) and total and segmented macular thickness (RNFL, ganglion cell layer (GCL), and inner plexiform layer (GCL)) were measured using Spectralis optical coherence tomography (OCT). Correlations between BCVA and OCT parameters or 30-2 VF parameters were assessed using Pearson correlation analysis. Multivariate regression analysis was performed to determine the factors associated with BCVA in advanced glaucoma patients. Peripapillary RNFL thickness, subfoveal choroidal thickness, and global macular RNFL, GCL, IPL, and total thickness were found to be significantly correlated with BCVA and central visual function. Multivariate analysis showed a significant correlation between subfoveal choroidal thickness and BCVA. In addition, central VF mean sensitivity, especially inferior hemifield, showed a significant relationship with BCVA. In conclusion, subfoveal choroidal thickness and central VF sensitivity, especially the inferior hemifield area, are factors that affect BCVA in advanced glaucoma.

Association of an Objective Structural and Functional Reference Standard for Glaucoma with Quality of Life Outcomes

PURPOSE

To compare self-reported quality-of-life (QoL) outcomes of patients diagnosed as normal, glaucoma suspect, and glaucoma based on an objective reference standard for glaucomatous optic neuropathy (GON).

DESIGN

Cross-sectional study.

PARTICIPANTS

1884 eyes of 1019 patients were included in the study.

METHODS

The data was sourced from the Duke Glaucoma Registry. Eyes were classified according to the presence and topographic correspondence of functional and structural damage, as assessed by parameters from standard automated perimetry (SAP) and spectral-domain OCT (SD-OCT). The objective diagnosis of the worse eye was used to define patient-level diagnosis. To assess QoL in the diagnostic groups, 14 unidimensional vision-related items of the National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25) were used to assess QoL in the diagnostic groups. Association between NEI VFQ-25 Rasch-calibrated scores and diagnostic groups was assessed through multivariable regression that controlled for confounding demographic and socioeconomic variables such as age, sex, race, income, marriage status, insurance status, and highest education level.

MAIN OUTCOME MEASURES

NEI VFQ-25 Rasch scores compared with objective criteria diagnosis based on SAP mean deviation (MD) and SD-OCT retinal nerve fiber layer (RNFL) thickness.

RESULTS

Overall, eyes classified as normal, glaucoma suspect, and glaucoma had decreasing mean scores in SAP MD (0.2 ± 1.0 dB, -0.9 ± 2.4 dB, -6.2 ± 7.0 dB, respectively; P < 0.001) and SD-OCT RNFL thickness (97.8 ± 9.5 μm, 89.0 ± 13.1 μm, 64.5 ± 12.8 μm, respectively; P < 0.001). The mean Rasch-calibrated NEI VFQ-25 score was significantly different among normal, suspect, and glaucoma groups (82.9 ± 13.0, 78.2 ± 14.8, and 72.6 ± 16.2, respectively; P < 0.001). When adjusted for confounding socioeconomic variables, glaucoma patients had significantly worse QoL than those classified as normal (β = -6.8 Rasch score units; P < 0.001).

CONCLUSION

A glaucoma diagnosis, based on an objective reference standard for GON, was significantly associated with worse Rasch-adjusted scores of QoL. Utilization of such objective criteria may provide clinically relevant metrics with potential to improve comparability of research findings and validation of newly proposed diagnostic tools.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Performance of a Glaucoma Screening Program Compared With Opportunistic Detection in China

PRCIS

Health examination center-based screening provide a good supplement to clinic-based glaucoma care by detecting early-stage glaucoma, especially those with normal intraocular pressure (IOP) and less visual impairment.

PURPOSE

Opportunistic glaucoma screening for early case identification is of great value in the prevention of severe visual impairment, however, novel, low-cost models are needed. We aimed to determine whether health examination center-based glaucoma screening identifies diseases earlier than outpatient cases in China.

MATERIALS AND METHODS

In this case-control study, 76 patients with primary glaucoma identified from a health examination center-based glaucoma screening program and 272 consecutive outpatient cases at the same hospital were enrolled from March 21 to September 30, 2016. Demographic characteristics, best-corrected visual acuity, IOP, mean deviation (MD), and pattern standard deviation (PSD) on Humphrey visual field testing in the better-seeing eye were compared between groups.

RESULTS

Screening-detected glaucoma patients had significantly lower IOP (18.3±4.2 mm Hg) than out-patient cases (26.7±12.6 mm Hg, P <0.001). Most (71.1%) of the screening-detected patients had IOP<21 mm Hg compared with 37.1% in the clinic group ( P <0.001). Seventy-five patients (98.7%) in the screening group were diagnosed as primary open angle glaucoma, compared with 44.1% in the clinic group ( P <0.001). Screening-detected patients had significantly less visual impairment than the clinic group (6.6% vs. 38.6%, P <0.05). Mean MD (-4.4±5.0 dB) and PSD (4.4±3.6 dB) for the screening group were superior to the clinic group (MD: -16.5±10.5 dB, P <0.001; PSD: 6.5±3.7 dB, P <0.001).

CONCLUSION

The glaucoma screening program was effective at detecting early disease, especially normal tension glaucoma and supplemented opportunistic detection of glaucoma.

Threat to fixation and vision-related quality of life in early open-angle glaucoma - results from the Glaucoma Intensive Treatment Study

PURPOSE

To determine the effect of glaucomatous visual field (VF) damage close to the point of fixation, called threat-to-fixation (TTF), on vision-related quality of life (VRQoL) in open-angle glaucoma.

METHODS

A total of 239 patients from the Glaucoma Intensive Treatment Study (GITS) were included in this analysis. The second VF of patients with newly diagnosed primarily early glaucoma was evaluated for the presence or absence of TTF. TTF was defined as VF loss including one or more of the four innermost test points depressed at p < 1% in the total deviation probability map of Humphrey 24-2 SITA Standard visual fields. VRQoL was evaluated using Rasch-analysed National Eye Institute Visual Function Questionnaire 25 (NEI VFQ-25) scores. The correlation between VRQoL and TTF was evaluated using uni- and multivariable regression analyses.

RESULTS

TTF was present in at least one eye in 115 patients (48%); located in the superior hemifield alone in 47% (54 of 115), in the inferior hemifield alone in 23% (27 of 115), and in 30% (34 of 115) in both hemifields. The median Rasch-calibrated NEI VFQ-25 scores were identical when comparing patients with TTF (VRQoL score 66, 95% CI: 23-100) and those with no-TTF (VRQoL score 66, 95% CI: 21-100) (p = 0.925). Neither the presence of TTF (R²  = -0.004, p = 0.968) nor the location of TTF (R²  = 0.023, p = 0.103) was significantly correlated to Rasch-calibrated NEI VFQ-25 scores.

CONCLUSION

The presence of TTF did not influence VRQoL, as measured by the NEI-VFQ-25, in this relatively large group of patients with mainly early glaucoma.

Surgical outcomes in only eye cataract surgery

INTRODUCTION

Performing cataract surgery in the setting of only one seeing-eye has significant benefits but also potential negative consequences for both patient and surgeon. This study investigates the surgical outcomes in patients undergoing cataract surgery on their only seeing-eye.

METHODS

A retrospective analysis was conducted in a single tertiary centre of all adult patients who had undergone cataract surgery on their only eye, where the fellow eye had a vision of 1.0 LogMAR or worse. Complication rates and visual outcomes were compared against data from the National Ophthalmology Database (NOD) Audit.

RESULTS

918 patients underwent cataract surgery on their only seeing-eye and had their postoperative visual acuity recorded. The overall unadjusted complication rate was 4.0% (versus 2.5% from NOD data) with the rate of posterior capsule rupture (PCR) being 1.9% (versus 1.14% from NOD data). 72.5% (versus 91.5% from NOD data) of patients attained a post-operative visual acuity of 0.3 LogMAR or better. The grade of surgeon performing the surgery did not have a statistically significant effect on the risk of complications.

DISCUSSION

In this cohort of only-eye patients undergoing cataract surgery, there was a small increased risk of operative complications including an increased, unadjusted risk of PCR, and fewer eyes achieved 0.3 LogMAR vision post-operatively compared to the NOD audit data. Grade of surgeon did not have an impact on the complication rate, indicating that with appropriate supervision, trainee surgeons may gain experience in only-eye surgery without additional risk to the patient. Further multicentre studies are recommended to assess reproducibility across units.

Vision-related quality of life amongst patients with low vision and blindness in a resource-limited country

PURPOSE

To evaluate the significance of sociodemographic and clinical variables on the quality of life of low-vision patients in a tertiary hospital in Enugu, Nigeria, and also determine the causative ocular pathologies and their vision-related quality of life.

METHODS

A cross-sectional study of adults 18 years and above with low vision/blindness. They were consecutively enrolled and clinically evaluated. The WHO-NEI-VFQ-25 questionnaire for quality of life was administered. Descriptive statistics were used to summarize variables. Kruskal-Wallis test, analysis of variance, and post hoc tests were done where appropriate.

RESULTS

Of the 400 participants, 81% were above 40 years. Mean age was 57.27 ± 16.34 years. Males (52.0%) and females (48.0%). 225 (56.25%) had Moderately Severe Visual Impairment. Low vision/blindness negatively affected the different domains of quality of life significantly, except ocular pain and dependency. Glaucoma and Cataract were the major disease conditions that affected most of the domains significantly. These conditions when poorly managed, due to poor and limited health resources, progress to low vision/blindness. Of all the socio-demographic factors and clinical variables studied, only age and severity of low vision were significant predictors of quality of life.

CONCLUSION

There is the need for prompt and proper treatment of low-vision patients and advocacy for the establishment of adequate and functional rehabilitation services. Quality of life which measures the overall impact of a disease on an individual was low in people with low vision and blindness. Low-vision services, which include rehabilitation, will provide comprehensive eye-care services and thus improve their quality of life.

Socio-Demographic, lifestyle and eye-related factors associated with quality of life Among people with glaucoma in Serbia

PURPOSE

The purpose of this study was to examine socio-demographic, lifestyle and ophthalmological factors associated with poorer Vision Related Quality of Life (VRQoL) in people with glaucoma.

METHODS

This cross-sectional study included 306 consecutive patients with glaucoma who presented for regular check-ups at the referral center in Belgrade (Serbia) from August 2015 to September 2016. The diagnosis of glaucoma was based on the glaucomatous disc cupping and reproducible visual field impairment on one or both eyes. Quality of life was examined using the validated Glaucoma Quality of Life-15 (GQL-15) and the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ 25).

RESULTS

A series of adjusted linear regression models showed that glaucoma patients with higher educational attainment, who were employed and still driving had better VRQoL. Worse visual acuity and visual field defect, being in later glaucoma stages, having lower intraocular pressure, having two laser interventions as well as having pseudo-exfoliative glaucoma was associated with worse VRQoL. Intake of fewer medications and having had no trabeculectomies on better eye as well as taking less drops per day on worse eye were associated with better VRQoL.

CONCLUSIONS

Several socio-demographic, lifestyle and ocular factors can impact VRQoL in glaucoma patients. Identifying people who are at risk of having worse VRQoL could allow for earlier interventions, such as changes in therapy, undergoing surgery, use of mobility aids etc.

Glaucoma Medication and Quality of Life after Phacoemulsification Combined with a Xen Gel Stent

Glaucoma has a significant impact on quality of life. Here, we aimed to evaluate the influence of a reduction in glaucoma medications on quality of life and patient satisfaction after phacoemulsification combined with the Xen gel stent. We carried out a cross-sectional survey of patients who underwent phacoemulsification with the Xen gel stent at the Medical University of Graz, Austria. Quality of life was assessed using the German version of the Glaucoma Symptoms Scale (GSS)—questionnaire. Patients were also asked whether the operation reduced glaucoma medications and to indicate their overall satisfaction from 1 (totally discontented) up to 10 (totally contented). Questionnaires of 80 patients were evaluated. A total of 36 patients (45.0%) reported a reduction in glaucoma medications. Three items of the GSS were significantly better in patients who needed fewer glaucoma medications after the operation (“hard to see in daylight”, 75.0 ± 31.1 vs. 57.7 ± 39.1, p = 0.035; “hard to see in dark places”, 81.1 ± 28.7 vs. 54.9 ± 41.2, p = 0.002; and “halos around lights”, 88.3 ± 25.9 vs. 68.8 ± 38.6, p = 0.002). Patient satisfaction was significantly higher when the procedure led to a reduction in glaucoma medication (8.3 ± 2.0 vs. 6.8 ± 3.1; p = 0.034). The reported quality of life and patient satisfaction were significantly better when phacoemulsification with the Xen gel stent reduced the number of glaucoma medications needed.

Prevalence of Open-angle Glaucoma in the Faroese Population

PURPOSE

The Faroe Islands are home to 50,000 genetically isolated people in the North Atlantic. The prevalence of open-angle glaucoma (OAG) in the Faroese population is unknown. Consequently, we conducted a survey to determine the prevalence of OAG in the Faroese population. We also investigated the role of known glaucoma-causing genes in Faroese OAG.

MATERIALS AND METHODS

We conducted a prospective survey of known and newly diagnosed glaucoma patients at the Faroese National Hospital, Landssjukrahusid, Tórshavn between October 1, 2015 to December 31, 2017. In addition we reviewed the only eye care provider in the Faroese Islands by scrutinizing electronic medical records between 2009 and June 15, 2014, October 1, 2015 and the partly overlapping prescriptions for ocular hypotensive medications in 2016 to identify patients with either a diagnosis of glaucoma, a diagnosis of ocular hypertension or a prescription for ocular hypotensive medications. Next, we prospectively confirmed diagnoses with complete eye examinations. Patient DNA samples were tested for variations in known glaucoma-causing genes [myocilin (MYOC), optineurin (OPTN), and TANK binding kinase 1 (TBK1)].

RESULTS

We determined the age-related prevalence of OAG January 1, 2017 in individuals 40 years or older to be 10.7/1000 (1.07%) and highly age-related. A diagnosis of OAG was present in 264 patients, of whom 211 (79.9%) had primary OAG (including normal tension glaucoma), 49 (18.6%) had pseudoexfoliation glaucoma, and 4 (1.5%) had pigmentary glaucoma. Among patients receiving medications for glaucoma, nearly 50% had primary OAG, while the majority of the rest had ocular hypertension or secondary glaucoma. No disease-causing variants were detected in MYOC, OPTN, or TBK1.

CONCLUSIONS

The calculated prevalence of OAG in the Faroe Islands was 1.07%. The absence of MYOC, OPTN, or TBK1 disease-causing variants in Faroese primary OAG patients suggests that a different, potentially unique set of genes may be contributing to the pathogenesis of glaucoma in this population.

Increased Near Activities Function Associated With Increased Glaucoma Medication Adherence Among Support, Educate, Empower (SEE) Participants

PRECIS

Higher levels of near vision-related quality of life (VRQoL) were associated with higher adherence to glaucoma medications after adjusting for important confounding variables among participants in the Support, Educate, Empower (SEE) personalized glaucoma coaching pilot study.

PURPOSE

To investigate the association between VRQoL and glaucoma medication adherence.

MATERIALS AND METHODS

Subjects were recruited for the SEE program, a prospective noncontrolled cohort study examining the impact of a personalized coaching program on glaucoma medication adherence. Glaucoma patients seen at the University of Michigan over 40 years old, taking ≥1 glaucoma medication, and self-reported poor adherence on 2 validated scales were recruited. Demographic details and VRQoL using the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) were collected. Participants' medication use for each prescribed glaucoma medication was captured electronically using a medication events monitoring system. The association between VRQoL and medication adherence was assessed with Pearson correlation coefficient (r) and linear regression.

RESULTS

Among the 95 eligible participants 49.5% were female, 55.3% were Caucasian, and mean age (±SD) was 63.8±10.5 years. Mean adherence to glaucoma medication was 73.8%±21.0%. Mean NEI VFQ-25 composite score was 81.6±14.5. Better medication adherence was significantly and positively correlated with better functioning in domains of ocular pain (r=0.20, P=0.048), near activities (r=0.29, P=0.004), and role difficulties (r=0.22, P=0.036). Linear regression models adjusting for known correlates of medication adherence (age, sex, race, income), showed a 10-unit increase in self-perceived near activities function was associated with a 2.2% increase in medication adherence (95% confidence interval, 1.0%-5.4%; P=0.0056).

CONCLUSION

Better self-perceived near activities function was associated with increased glaucoma medication adherence.

A Scoping Review of Quality of Life Questionnaires in Glaucoma Patients

PRECIS

Multiple questionnaires exist to measure glaucoma's impact on quality of life (QoL). Selecting the right questionnaire for the research question is essential, as is patients' acceptability of the questionnaire to enable collection of relevant patient-reported outcomes.

PURPOSE

QoL relating to a disease and its treatment is an important dimension to capture. This scoping review sought to identify the questionnaires most appropriate for capturing the impact of glaucoma on QoL.

METHODS

A literature search of QoL questionnaires used in glaucoma, including patient-reported outcomes measures, was conducted and the identified questionnaires were analyzed using a developed quality criteria assessment.

RESULTS

Forty-one QoL questionnaires were found which were analyzed with the detailed quality criteria assessment leading to a summary score. This identified the top 10 scoring QoL questionnaires rated by a synthesis of the quality criteria grid, considering aspects such as reliability and reproducibility, and the authors' expert clinical opinion. The results were ratified in consultation with an international panel of ophthalmologists (N=49) from the Educational Club of Ocular Surface and Glaucoma representing 23 countries.

CONCLUSIONS

Wide variability among questionnaires used to determine vision related QoL in glaucoma and in the responses elicited was identified. In conclusion, no single existing QoL questionnaire design is suitable for all purposes in glaucoma research, rather we have identified the top 10 from which the questionnaire most appropriate to the study objective may be selected. Development of a new questionnaire that could better distinguish between treatments in terms of vision and treatment-related QoL would be useful that includes the patient perspective of treatment effects as well as meeting requirements of regulatory and health authorities. Future work could involve development of a formal weighting system with which to comprehensively assess the quality of QoL questionnaires used in glaucoma.

If we don't change direction soon, we'll end up where we're going: a description of the SSY Engine

Data presented during the first two decades of this millennium has shed valuable light on how the intraocular pressure (IOP) is linked to glaucomatous progression. Large prospective controlled trials have confirmed that there is a correlation between the change in intraocular pressure (IOP) and the risk for visual field progression. The magnitude of the effect, as indicated by these studies, is a 10-15% decrease in risk for a 1 mmHg drop in IOP. The risk is correlated with the rate at which patients develops field loss, that is the Rate of Progression or RoP, which in turn makes future projections of a patient's progression over time at a given IOP level a reasonable possibility. This led to the creation of the SSY (Save Sight Years) concept and later the SSY engine, which is a practical application of this model in the form of a web application. This article describes the thinking behind this system, how it works, the caveats and where we think it can benefit clinical practice.

Interpretation of change scores for the National Eye Institute Visual Function Questionnaire-25: the minimally important difference

AIM

To estimate the minimally important difference (MID) in change in National Eye Institute Visual Function Questionnaire-25 (VFQ-25) composite score using methods aligned with patient perception.

METHODS

Retrospective analysis of prospectively collected data from adults with primary angle closure or primary angle closure glaucoma enrolled in the Effectiveness, in Angle-closure Glaucoma, of Lens Extraction study. We included data from 335 participants with patient reported visual function (VFQ-25) and health status measured by the EQ-5D-3L over 36 months. We used the recommended anchor-based methods (receiver operating characteristic (ROC), predictive modelling and mean change) to determine the MID of the VFQ-25. EQ-5D-3L anchor change was defined as none (<0.065); minimal (0.065≤EQ-5D-3L change ≤0.075 points) and greater change (>0.075 points).

RESULTS

Mean baseline VFQ-25 score was 87.6 (SD 11.8). Estimated MIDs in the change in VFQ-25 scores (95% CI) were 10.5 (1.9 to 19.2); 3.9 (-2.3 to 10.1); 5.8 (1.9 to 7.2) and 8.1 (1.7 to 14.8) for the 'within-patient', 'between-patient' change, ROC and predictive modelling anchor methods respectively. Excluding estimates from the methodologically weaker 'within-patient' method, the MID of a change in VFQ-25 composite score is 5.8 (median value).

CONCLUSIONS

Estimates of the MID using multiple methods assist in the interpretation of the VFQ scores. In the context of early glaucoma related visual disability, a change score of around six points on the VFQ-25 is likely to be important to patients. Further confirmatory research is required. Studies comparing changes in patient-reported outcome measure scores with a global measure of patients' perceived change are required.

The effects of age-related macular degeneration on quality of life in a Brazilian population

BACKGROUND

To evaluate the impact of age-related macular degeneration (AMD) on the quality of life (QoL) in a Brazilian population using The National Eye Institute-Visual Function Questionnaire-25 (NEI-VFQ-25).

METHODS

This observational study included 462 participants from the Departments of Ophthalmology of the University of Campinas and Conderg-Divinolândia. The NEI-VFQ-25 questionnaire and Rasch analysis were used to assess the vision-related quality of life (VRQoL). Patients with macular neovascularization were interviewed at enrollment and after three loading doses of intravitreal anti-vascular endothelial growth factor (anti-VEGF) treatment.

RESULTS

One hundred thirty-three patients were excluded because they had another ophthalmic disease, for a total of 349 patients included in the study (177 in the AMD group, 172 in the control group; 56.4% were women; mean ± standard deviation age, 70.6 ± 9.5 years). Most NEI-VFQ-25 subscale scores were significantly lower in the AMD group compared with the control group. The Rasch-calibrated NEI-VFQ-25 median score in the visual-functioning component was 56.41 for the AMD group and 61.53 for the control group, a difference of ± 4.00 (P = 0.0001). Separate analyses of the sociodemographic and ocular characteristics showed that the NEI-VFQ-25 scores were affected mostly by family income, educational level, descent, diet (vegetables/fruits), physical activity, and visual acuity (VA). The longitudinal component assessed a different group of 48 patients with exudative disease treated with anti-VEGF drugs. The mean logarithm of the minimum angle of resolution change in VA in treated eyes was a 0.16 decrease (P = 0.01). The mean change in the optical coherence tomography macular thickness was a 36.74-μm decrease (P = 0.012) from baseline to 4 months. The mean NEI-VFQ-25 scores improved significantly from baseline to follow-up at 4 months in almost all subscales.

CONCLUSIONS

In a Brazilian community, patients with AMD had a worse VRQoL than controls. The AMD severity and bilaterality were associated with decreased NEI-VFQ-25 scores. Higher family income, educational level, descent, and lifestyle significantly improved several subscales of the NEI-VFQ-25 questionnaire. Treated patients with exudative AMD had improvements in the VA, macular thickness, and most NEI-VFQ-25 subscale scores.

The Effect of Glaucoma on the Quality of Patient’s Life

Glaucoma is a chronic, progressive opticopathy with morphological optic disc changes and visual field disturbances. Visual field disturbances change the patient’s life habits. Medical as well as surgical treatments also disturb patients` activities of daily living. According to this, glaucoma is the disease which affects quality of patient’s life (QQL). Visual field (VF) evaluation is very important in glaucoma disease diagnostic process. Location of the VF defects also have an impact on the QOL. Patient`s daily activities, such as walking, low light condition adaptation, peripheral seeing of the objects, can be affected by glaucoma progression and with VF defects. All social, religious, cultural and traveling events are more difficult for the severe glaucomatous patients (MD<-12dB) in comparison with mild glaucomatous, defined as patients with MD > −6 dB. Every day usage of the local antuglaucomatous therapy disturbs patients’ QOL. The side effects of the eye drops can produce burning sensation, bronchospasm, bradycardia, increased iris pigmentation, increased eyelash length. Also, locally applied therapy provokes ocular surface disease. Benzalkonium chloride provokes destruction of the epithelial cells junction with development of the epitheliopathy and ocular surface disease. Surgically treated glaucoma patients can have disturbed QOL due to ocular surface disease symptoms (foreign body sensation, eye pain, redness, and increased tearing). These symptoms are caused by trabeculectomy and they are correlated with filtering bleb existence.To achieve QOL of the glaucomatous patients, different founded instruments are used. They are classified in: general health, vision specific, and glaucoma specific.

Predicting Adherence With the Glaucoma Treatment Compliance Assessment Tool

PRéCIS:: Univariate and multivariable models using the Glaucoma Treatment Compliance Assessment Tool (GTCAT) statements identified multiple, patient-specific factors associated with adherence that could be used to inform personalized interventions to optimize glaucoma adherence.

PURPOSE

The purpose of this study was to determine the health behavior factors related to glaucoma adherence in patients with self-reported poor adherence.

METHODS

A research coordinator used the Chang Adherence Measure and the Morisky Medication Adherence Scale to identify subjects with poor self-reported glaucoma medication adherence and enrolled them in a 3-month study to electronically monitor medication adherence. At enrollment, the coordinator administered the GTCAT. We calculated the percentage of prescribed doses taken over a 3-month period using an electronic dose monitor (AdhereTech). We used Rasch analysis, and univariate and multivariable regression to determine the GTCAT statements that predicted electronically monitored adherence.

RESULTS

The mean adherence was 73.8% (SD=21.04%, range: 13% to 100%). Rasch analysis showed that the GTCAT had a good overall fit and no differential bias (Anderson likelihood ratio test >0.05). Multiple GTCAT statements were associated with adherence, which represented increased knowledge, increased cues-to-action, decreased barriers, less depression, and increased self-efficacy (P<0.09 for each). The full GTCAT or a subset of statements had a high association with adherence (R range: 0.44 to 0.51, P<0.005 for all). The GTCAT identified >50% of patients who wanted more education about glaucoma; >68% who did not use reminders; and >40% who reported having difficulty using the eye drops.

CONCLUSIONS

The GTCAT identified multiple factors associated with adherence. Clinicians and researchers could use this tool to identify specific barriers to adherence and develop potential interventions to improve adherence.

A Review of Studies of the Association of Vision-Related Quality of Life with Measures of Visual Function and Structure in Patients with Glaucoma in the United States

Purpose: To investigate the association of quality of life (QoL) with ocular structure and function in glaucoma patients, and to identify which aspects of QoL are most closely tied to Visual Field (VF) and Visual Acuity (VA).Methods: We conducted a comprehensive review of studies on QoL in glaucoma patients using PubMed, Web of Science, and Google Scholar (from 1 January 1997 to 7 December 2019). A total of 21 studies in the United States that used the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ) or 51-item NEI VFQ were included. A descriptive analysis of data from the selected studies was conducted. The association between QoL scores and visual function and structure was investigated by ranking the strength of association on a scale from 1 (weakest) to 12 (strongest).Results: Studies reported correlations between QoL scores and Visual Structure. Associations were also reported between QoL and Visual Function both cross-sectionally and longitudinally, with a stronger association of VF and VA with distance activities (average ranking 9.1 and 9.6), vision-specific dependency (8.7 and 8.9), and driving (8.6 and 9.7). Vision-specific mental health (6.5 and 4.9), vision-specific social functioning (8.4 and 6.2), and vision-specific role difficulties (7.1 and 6.6) domains were more associated with VF than with VA.Conclusion: Our study was the first to quantify and rank the strength of association between visual function and QoL domains. Driving and psycho-social QoL domains tended to be most affected by glaucoma-related deterioration of visual function. QoL scores could be used for more patient-centered disease management.

What do patients with glaucoma see: a novel iPad app to improve glaucoma patient awareness of visual field loss

Purpose

Glaucoma patients with peripheral vision loss have in the past subjectively described their field loss as ‘blurred’ or ‘no vision compromise’. We developed an iPad app for patients to self-characterise perception within areas of glaucomatous visual field loss.

Methods

Twelve glaucoma patients with visual acuity ≥20/40 in each eye, stable and reliable Humphrey Visual Field (HVF) over 2 years were enrolled. An iPad app (held at 33 cm) allowed subjects to modify ‘blur’ or ‘dimness’ to match their perception of a 2×2 m wall-mounted poster at 1 m distance. Subjects fixated at the centre of the poster (spanning 45° of field from centre). The output was degree of blur/dim: normal, mild and severe noted on the iPad image at the 54 retinal loci tested by the HVF 24-2 and was compared to threshold sensitivity values at these loci. Monocular (Right eye (OD), left eye (OS)) HVF responses were used to calculate an integrated binocular (OU) visual field index (VFI). All three data sets were analysed separately.

Results

36 HVF and iPad responses from 12 subjects (mean age 71±8.2y) were analysed. The mean VFI was 77% OD, 76% OS, 83% OU. The most common iPad response reported was normal followed by blur. No subject reported dim response. The mean HVF sensitivity threshold was significantly associated with the iPad response at the corresponding retinal loci (For OD, OS and OU, respectively (dB): normal: 23, 25, 27; mild blur: 18, 16, 22; severe blur: 9, 9, 11). On receiver operative characteristic (ROC) curve analysis, the HVF retinal sensitivity cut-off at which subjects reported blur was 23.4 OD, 23 OS and 23.3 OU (dB).

Conclusions

Glaucoma subjects self-pictorialised their field defects as blur; never dim or black. Our innovation allows translation of HVF data to quantitatively characterise visual perception in patients with glaucomatous field defects.

Only eye study 2 (OnES 2): 'Am I going to be able to see when the patch comes off?' A qualitative study of patient experiences of undergoing high-stakes only eye surgery

OBJECTIVES

Ocular surgery is a source of significant concern for many patients, especially in high-stakes circumstances. The purpose of this study was to explore patient experiences of undergoing surgery on their only-seeing eye.

DESIGN

A qualitative investigation using semistructured face-to-face interviews. Transcripts were analysed using thematic analysis.

SETTING

Hospital eye service in the UK.

PARTICIPANTS

Twelve participants with a diagnosis of glaucoma with worse eye visual acuity <3/60± end-stage visual field loss. All participants had experience of undergoing surgery on their better-seeing (ie, 'only') eye.

RESULTS

Data were coded into three key themes relating to (1) emotional impact of surgery, (2) burden of visual loss and (3) coping with surgery. Patients reported depressive symptoms at all stages of their surgical journey; concern about poor visual outcomes was a common feature. Only eye surgery imposes an emotional burden due to the uncertainty regarding individuals' ability to continue daily activities and maintaining social roles. Burden extended to the inconvenience of frequent hospital visits and difficulties with follow-up care. Participants' ability to cope effectively with surgery appeared to be linked to extent of support from healthcare professionals. Key areas in developing trust and support were an open and transparent dialogue between surgeons and patients, continuity of care, patient inclusion in decision-making, and observable empathy.

CONCLUSIONS

The findings indicate a need for an enhanced model of care in only eye surgery to better target patient preferences and allay concerns inherent with these procedures.

The worse eye revisited: Evaluating the impact of asymmetric peripheral vision loss on everyday function

In instances of asymmetric peripheral vision loss (e.g., glaucoma), binocular performance on simple psychophysical tasks (e.g., static threshold perimetry) is well-predicted by the better seeing eye alone. This suggests that peripheral vision is largely 'better-eye limited'. In the present study, we examine whether this also holds true for real-world tasks, or whether even a degraded fellow eye contributes important information for tasks of daily living. Twelve normally-sighted adults performed an everyday visually-guided action (finding a mobile phone) in a virtual-reality domestic environment, while levels of peripheral vision loss were independently manipulated in each eye (gaze-contingent blur). The results showed that even when vision in the better eye was held constant, participants were significantly slower to locate the target, and made significantly more head- and eye-movements, as peripheral vision loss in the worse eye increased. A purely unilateral peripheral impairment increased response times by up to 25%, although the effect of bilateral vision loss was much greater (>200%). These findings indicate that even a degraded visual field still contributes important information for performing everyday visually-guided actions. This may have clinical implications for how patients with visual field loss are managed or prioritized, and for our understanding of how binocular information in the periphery is integrated.

Vision-related Quality of Life in Glaucoma Patients and its Correlations With Psychological Disturbances and Visual Function Indices

PURPOSE

The purpose of this study was to assess the vision-related quality of life (VR-QoL) in glaucoma patients and its correlations with psychological disturbances and visual function components.

MATERIALS AND METHODS

The 25-item National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25) and Hospital Anxiety and Depression Scale (HADS) questionnaires were administered to 428 Chinese glaucoma patients to evaluate their VR-QoL and anxiety and depression disorders, respectively. Sociodemographical and clinical factors were collected at the same time. Univariate analyses were used to investigate the associations between the variables and the VR-QoL. Multivariate linear regression analyses were used to identify the independent psychological and visual functional predictors of the VR-QoL. Standardized partial regression analyses were used to reveal the variables that mostly relevant to the VR-QoL.

RESULTS

The composite score (mean±SD) was 71.88±14.44 for NEI VFQ-25 and 13.17±6.56 for HADS. Visual function indices, including best-corrected visual acuity and mean deviation of both eyes in addition to psychological symptoms including anxiety and depression were both correlated with VR-QoL significantly, even after adjusting for sociodemographical and clinical factors. Standardized partial regression analyses further suggested that psychological disorders, especially anxiety rather than visual function components, were mostly relevant to VR-QoL.

CONCLUSIONS

Deterioration of vision impairment and visual field defects in addition to increased recognition of psychological disturbances reduce the VR-QoL of glaucoma patients significantly. Alleviating psychological symptoms, especially anxiety, perhaps have a greater influence on the improvement of VR-QoL.

Vision-related and health-related quality of life in patients with giant cell arteritis

OBJECTIVE

To establish if there is a difference in health-related quality of life and vision-related quality of life in patients with a confirmed diagnosis of giant cell arteritis compared with those with clinical features suspicious for the disease at initial presentation but in whom giant cell arteritis is ultimately excluded.

METHODS

A cross-sectional study of 116 patients who presented to two tertiary referral hospitals in Ireland with symptoms suspicious for giant cell arteritis was performed between August 2011 and June 2017. The Vision Core Measurement 1 and Short Form-36 questionnaires were used as assessment tools.

RESULTS

The mean (standard deviation) age of all 116 participants was 69.4 (9.3) years of whom 74 (63.8%) were female. In the giant cell arteritis group, 19.7% had permanent loss of vision and 54.7% had non-permanent visual disturbance. Vision Core Measurement 1 score in the giant cell arteritis group correlated with worse eye visual acuity (r = 0.4233, p = 0.0002). The Short Form-36 subscales of role physical (p = 0.0002), role emotional (p = 0.024), and the mental composite score (p = 0.012) were significantly worse in patients with giant cell arteritis. A significant correlation was found between vision-related quality of life scores and all Short Form-36 subscale scores except bodily pain (r = -0.215 to -0.399, p < 0.05 for all), and between social functioning and visual acuity in the better eye (r = -0.242, p = 0.038).

CONCLUSION

Vision-related quality of life is an important subjective concern for both patients presenting with a suspicion of giant cell arteritis and those with a definite diagnosis of giant cell arteritis. Features of giant cell arteritis impact on patients' physical and emotional states and vision influences global quality of life in giant cell arteritis. A long-term multidisciplinary approach is warranted for clinical, physical, and psychological treatment and support.

The Only Eye Study (OnES): a qualitative study of surgeon experiences of only eye surgery and recommendations for patient safety

OBJECTIVE

Performing surgery on patients with only one seeing-eye, where complications may result in catastrophic vision loss, presents unique challenges for the ophthalmic care team. There is currently no evidence regarding how surgeons augment their care when treating only eye patients and no guidelines for how these patients should be managed in hospital eye services. This study aimed to explore ophthalmic surgeons' experiences of only eye surgery and perceptions of current practice.

DESIGN AND PARTICIPANTS

Ten ophthalmic surgeons were asked to relate their experiences and views on performing only eye surgery in indepth, semistructured interviews. Interviews were audio-recorded and transcribed. Qualitative data were subjected to thematic analysis to identify key themes.

SETTING

Hospital eye service.

RESULTS

Five key themes emerged relating to surgeons' experiences and perceptions of only eye surgery: (1) differences in approach to consent, (2) strategies for risk reduction, (3) unmet training needs, (4) value of surgical mentor and (5) emotional impact of unsuccessful outcomes. Recommendations for improving the surgical journey for both the patient and the surgeon related primarily to better recognition and understanding of the complexities inherent with only eye surgery.

CONCLUSIONS

Outcomes of only eye surgery may be improved through a number of methods, including development of purpose-designed training fellowships, adoption of stress-reducing strategies and enhancement of available support services. The findings identify emerging themes unique to only eye surgery and the need for guidelines on the provision of care for these high-stakes surgical patients.

Psychometric properties of the Portuguese version of the National Eye Institute Visual Function Questionnaire-25

BACKGROUND

To investigate the psychometric properties of the Brazilian Portuguese version of the National Eye Institute Visual Function Questionnaire (NEI VFQ-25) questionnaire in a group of patients with different eye diseases.

METHODS

Cross-sectional study. All subjects completed the Portuguese version of the NEI VFQ-25 questionnaire. Another questionnaire containing a survey about clinical and demographics data was also applied. Rasch analysis was used to evaluate the psychometric properties of the NEI VFQ-25.

RESULTS

The study included 104 patients with cataract, 65 with glaucoma and 83 with age macular degeneration. Mean age was 70.7 ± 9.9 years, with 143 female (56.7%) and 109 male patients (43.2%). Mean visual acuity was 0.47 and 1.17 logMAR in the better and worse eye, respectively. According to Rasch analysis, seven items were found to misfit. Those items belonged to the following subscales: general health, social function, mental health, ocular pain and role limitations. The principal component analysis of the residuals showed that 55.5% of the variance was explained by the principal component. Eight items loaded positively onto the first contrast with a correlation higher than 0.4. These items belonged to the following subscales: near vision, distance vision, mental health and dependency. After excluding those items, we were able to isolate items from the NEI VFQ-25, related only to a visual functioning component. Finally, the principal component analysis from residuals of this revised version of the NEI VFQ-25 (items related to visual function) showed that the principal component explained 61.2% of the variance, showing no evidence of multidimensionality.

CONCLUSIONS

The Portuguese version of the NEI VFQ-25 is not a unidimensional instrument. We were able to find items that belong to a different trait, possible related to a socio-emotional component. Thus, in order to obtain psychometrically valid constructs, both the visual functioning and socio-emotional components should be analyzed separately.

Taking the strain? Impact of glaucoma on patients' informal caregivers

PURPOSE

To estimate informal caregiver (ICG) strain in people from a glaucoma clinic.

METHODS

Patients with glaucoma were consecutively identified from a single clinic in England for a cross-sectional postal survey. The sample was deliberately enriched with a number of patients designated as having advanced glaucoma (visual field [VF] mean deviation worse than -12 dB in both eyes). Patients were asked to identify an ICG who recorded a Modified Caregiver Strain Index (MCSI), a validated 13 item instrument scored on a scale of 0-26. Previous research has indicated mean MCSI to be >10 in multiple sclerosis and Parkinson's disease. All participants gave a self-reported measure of general health (EQ5D).

RESULTS

Responses from 105 patients (43% of those invited) were analysed; only 38 of the 105 named an ICG. Mean (95% confidence interval [CI]) MCSI was 2.4 (1.3, 3.6) and only three ICGs recorded a MCSI > 7. The percentage of patients with an ICG was much higher in patients with advanced VF loss (82%; 9/11) when compared with those with non-advanced VF loss (31%; 29/94; p = 0.001). Mean (standard deviation) MCSI was considerably inflated in the advanced patients (5.6 [4.9] vs 1.5 [2.2] for non-advanced; p = 0.040). Worsening VF and poorer self-reported general health (EQ5D) of the patient were associated with worsening MCSI.

CONCLUSION

ICG strain, as measured by MCSI, for patients with non-advanced glaucoma is negligible, compared with other chronic disease. ICG strain increases moderately with worsening VFs but this could be partly explained by worse general health in our sample of patients.

Influence of Sociodemographic Factors on Disease Characteristics and Vision-related Quality of Life in Primary Open-angle Glaucoma Patients: The Italian Primary Open Angle Glaucoma Study (IPOAGS)

PURPOSE

The purpose of this article was to evaluate the potential association between sociodemographic factors with clinical characteristics, vision-related quality of life (QoL), and glaucoma-related symptoms scores in a large cohort of primary open-angle glaucoma patients.

MATERIALS AND METHODS

Multicenter, cross-sectional study involving academic and nonacademic centers. Previously diagnosed primary open-angle glaucoma patients aged >18 years were enrolled. At baseline, information on demographic characteristics, social, medical and ocular history, clinical presentation and treatments was collected. Vision-related QoL was evaluated by means of the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25), while glaucoma-related symptoms were evaluated using the Glaucoma Symptom Scale (GSS) questionnaire. The associations between sociodemographic factors with clinical characteristics (mean deviation, pattern standard deviation, best-corrected visual acuity), NEI-VFQ-25, and GSS scores were evaluated by means of univariate and multivariate general linear models.

RESULTS

A total of 3227 patients were enrolled. Older age and male sex were significantly associated with lower mean deviation (P<0.01) and higher pattern standard deviation (P<0.01), whereas older age was associated with lower best-corrected visual acuity (P<0.01). The composite GSS score was related to age (P=0.02), sex (P<0.01), employment (P=0.01), and profession (P=0.04), while the total NEI-VFQ-25 score was associated with sex (P<0.01), marital status (P=0.02), and employment (P=0.02).

CONCLUSIONS

Age and sex were significantly associated with almost all indicators of glaucoma severity at baseline. Other variables, such as employment, profession, and marital status were significantly associated with vision-related QoL scores.

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.

Correlation Between Visual Function and Performance of Simulated Daily Living Activities in Glaucomatous Patients

PURPOSE

To analyze the correlations between functional clinical tests and the performance of glaucoma patients in simulated daily living activities.

PATIENTS AND METHODS

Thirty-two patients with chronic glaucoma, followed at the Quinze-Vingts National Ophthalmology Hospital, were included. All patients had a clinical evaluation of visual function including best-corrected visual acuity, contrast sensitivity, and monocular and binocular visual field (VF) tests. Four different simulated activities of daily living were evaluated in standardized artificial platforms (StreetLab and HomeLab): "mobility" and an obstacle avoidance task in an artificial street, "reaching and grasping" large and small objects on a kitchen work surface, "localization of people" and "face orientation recognition." Patient performance in the different tasks was correlated with VF evaluation including integrated binocular visual field (IVF), VF mean deviation (MD) of the better and the worse eye, Esterman binocular VF, best-corrected visual acuity, and contrast sensitivity.

RESULTS

The IVF score was significantly correlated with "localization of people" time (r=0.49; P=0.003), "face orientation recognition" time (r=0.50; P=0.002), and "movement onset" for reaching and grasping small objects (r=0.38; P=0.029). The MD of the better eye appeared significantly correlated with "face orientation recognition" time (r=-0.44; P=0.009) and "localization of people" time (r=-0.46; P=0.005). The Esterman score appeared significantly correlated with "mobility time" (r=-0.40; P=0.018), "localization of people" (r=-0.37; P=0.030), "face orientation recognition" times (r=-0.39; P=0.024), and "movement onset" for reaching and grasping large objects (r=-0.43; P=0.015).

CONCLUSIONS

The IVF score and the MD of the better eye appeared to better evaluate "reaching and grasping," "face orientation recognition," and "localization of people" simulated tasks, whereas for the "mobility" task, the Esterman VF seemed more useful. The precise evaluation of the glaucoma patient's ability to perform everyday life tasks is complex and may require both monocular and binocular VF tests.

Psychometric Properties of the Glaucoma Treatment Compliance Assessment Tool (GTCAT) in a Brazilian Population

PURPOSE

To determine the psychometric properties of a reduced version of the Glaucoma Treatment Compliance Assessment Tool (GTCAT), which was translated to Brazilian Portuguese.

PATIENTS AND METHODS

We translated into Portuguese the GTCAT using validated techniques and administered it to a group of glaucoma patients using at least 1 ocular hypotensive eye drop medication. We used principal components analysis to determine construct validity, Rasch analysis, and Cronbach α for internal consistency reliability, frequency analysis for floor and ceiling effects, and Spearman ρ for test-retest reliability.

RESULTS

We included 76 glaucoma patients. Principal component analysis loaded 14 questions into 7 components that were consistent with the Health Belief Model. The components were related to "barriers due to lack of drops," "self-efficacy," "experience of negative effects of the disease," "well-being," "general glaucoma knowledge," "glaucoma symptoms," and "cues-to-action." No statements had floor or ceiling effects, and all statements had acceptable test-retest reliability. Components had internal consistency Cronbach α reliability between 0.125 and 0.794. and average Spearman ρ reliability was 0.73, ranging from 0.44 to 1.00. According to Rasch analysis, the mean (±SD) of the person measures was 0.24±0.15 logits, person separation index was 0.58, and person reliability 0.25.

CONCLUSIONS

The Portuguese-translated version of the GTCAT showed acceptable psychometric properties. With further refinement, clinicians and researchers could use it to better investigate glaucoma adherence issues in the Brazilian population.

Xen45 Gel Stent implant: patient reported outcomes

Our aim was to report quality of life (QOL) outcomes following Xen45 Gel Stent implantation surgery in patients suffering with primary open angle glaucoma (POAG). A retrospective analysis was performed on all patients who had Xen45 implantation surgery during a 2-year period (Jun, 2016-Apr, 2018). Of 52 consecutive patients were included with a total of 58 eyes being operated on. QOL was compared both pre-operatively and 6 weeks post-operatively using the GQL-15 questionnaire. There was an overall improvement in GQL-15 summary scores for our patient group. All item scores showed either no change or some degree of improvement. The Xen45 Gel Stent Implant is a promising new intervention which has shown improved QOL scores in our patient group. Further, higher power studies are now needed to compare the Xen45 to trabeculectomy (TE), which is currently the gold standard.

Factors Associated With Health-Related Quality of Life in Medically and Surgically Treated Patients With Glaucoma

Importance

Health-related quality of life (HRQOL) is often reduced with glaucoma, but associated factors are poorly understood.

Objective

To determine factors associated with reduced HRQOL in medically and surgically treated patients with glaucoma.

Design, Setting, and Participants

Prospective cohort study at a tertiary referral glaucoma practice, with 160 consecutive, prospectively enrolled medically or surgically treated adult patients with glaucoma.

Main Outcome and Measures

All patients completed 2 HRQOL questionnaires (the 25-item National Eye Institute Visual Function Questionnaire and the Adult Strabismus-20 questionnaire [AS-20]). Thirty-six patients had undergone glaucoma drainage device surgery, 51 underwent trabeculectomy, and 73 were medically treated. Factors considered for association with HRQOL in multiple regression analyses were age, sex, best-eye and worst-eye mean deviation on Humphrey visual fields, treatment modality, best-eye and worst-eye visual acuity, and diplopia.

Results

The mean (SD) age of participants was 69 (13) years, 63% were female, 97% were white, 93% were not Hispanic, and the mean deviation (SD) was -13 (10) dB. Reduced HRQOL was associated with worse diplopia (Diplopia Questionnaire score) on 6 subscales (range of partial r2 [rp2], 0.207-0.069). Reduced HRQOL was associated with lower best-eye mean deviation on 5 of 6 subscales (rp2 range, 0.379-0.027), lower worst-eye mean deviation on 4 of 6 (rp2 range, 0.242-0.046), treatment group on 3 of 6 (rp2 range, 0.190-0.025), lower worst-eye visual acuity on 5 of 6 (rp2 range, 0.063-0.025), lower best-eye visual acuity on 2 of 6 (rp2 range, 0.032-0.017), and younger age on 2 of 6 (rp2 range, 0.021-0.014). In adjusted analyses, glaucoma drainage device was associated with worse HRQOL in 3 AS-20 subscales compared with trabeculectomy and 2 AS-20 subscales compared with medical. Differences ranged from -14.7 to -7.4, with half the absolute magnitude of the full range of the 95% CI ranging from 9.2 to 5.7.

Conclusions and Relevance

Our findings support the assertion that reduced HRQOL is common in surgically and medically treated patients with glaucoma. Overall, poor HRQOL in patients with glaucoma is moderately associated with worse diplopia, lower mean deviation on visual field testing in either eye, poorer visual acuity in either eye, treatment type, and younger age. Previous glaucoma drainage device surgery was specifically associated with poorer HRQOL compared with trabeculectomy or medical treatment. Psychosocial effects of glaucoma drainage device should be considered when counseling patients with glaucoma.

Vision-related quality of life according to location of visual field loss in patients with glaucoma

PURPOSE

To assess influence of the location of visual field (VF) loss on vision-related quality of life (VRQOL) in patients with glaucoma.

METHODS

We included 826 patients with primary open-angle glaucoma (POAG) enrolled in the prospectively designed Life Quality of Glaucoma Patients Who Underwent Treatment (LIGHT) study organized by the Korean Glaucoma Society. We divided the integrated binocular visual field (IVF) into four regions and evaluated the associations between Rasch-analysed 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) and location of the IVF using univariate and hierarchical multivariable linear regression.

RESULTS

Mean deviation (MD) of the IVF at superior centre showed the lowest value among the four regions. Multivariable linear regression analysis revealed significant correlation of the composite score and all subscales of the NEI VFQ-25 except ocular pain and near activities at each of four IVF regions. Mean deviation at superior centre showed significant correlation with composite score (R²  = 0.181), near activities (R²  = 0.175), and social functioning (R²  = 0.166); MD at superior periphery showed highest correlation with role difficulties (R²  = 0.137); MD at inferior centre showed highest correlation with driving (R²  = 0.145); and MD at inferior periphery showed significant correlation with distance activities (R²  = 0.214) and dependency (R²  = 0.119).

CONCLUSION

Four different regions of the IVF had a similarly important impact on subscales of the NEI VFQ-25 in glaucoma patients. Preservation of the superior field should be considered as much as that of the inferior field for maintaining a good VRQOL in patients with glaucoma.

Associations of subjective and objective clinical outcomes of visual functions with quality of life in Chinese glaucoma patients: a cross-sectional study

BACKGROUND

The cost of managing a chronic disease like glaucoma is quite large. A convenient and economical monitoring tool like self-reported measures of Quality of Life (QoL) could have the potential to significantly reduce the health economic burden of this disease. However, evidence about whether QoL can effectively reflect both subjective and objective clinical outcomes of visual functions in glaucoma patients is lacking. In this paper, we examined the relationships between both subjective and objective visual functions and QoL in glaucoma patients.

METHODS

This cross-sectional study enrolled 107 patients with a broad range of glaucomatous visual function loss. Subjective visual function loss was assessed using tests of visual acuity (VA), contrast sensitivity (CS) and visual field (VF). Evaluation of objective visual function was performed using pattern visual evoked potentials (PVEP). National Eye Institute Visual Function Questionnaire 25 (NEI VFQ-25) and Glaucoma Quality of Life-15 (GQL-15) were used to measure QoL. Uni- and multivariable linear regression analyses were performed to investigate the associations between all the clinical variables with Rasch-calibrated QoL scores.

RESULTS

Univariate analysis revealed that worse Rasch-calibrated NEI VFQ and GQL scores were associated with poorer VA and CS in both the better eye (BE) and the worse eye (WE), and with worse VF mean deviation, VF pattern standard deviation and PVEP latency and amplitude in 15 min check size in the WE (P < 0.05). Multivariable linear regression analysis revealed that, after adjusting for age, gender, duration of glaucoma, glaucoma severity and glaucoma type, Rasch-calibrated NEI VFQ-25 person measure scores were significantly associated with PVEP latency in 15 min check size [β = - 0.347, 95% CI: (- 0.618, - 0.118), P = 0.001] in the WE; Rasch-calibrated GQL-15 person measure scores were significantly associated with PVEP amplitude in 15 min check size [β = - 0.338, 95% CI: (- 0.588, - 0.108), P < 0.001] in the WE.

CONCLUSIONS

Self-reported measures of QoL could be supplemental tools for assessing both subjective and objective visual functions in glaucoma patients.

Vision-related quality of life and symptom perception change over time in newly-diagnosed primary open angle glaucoma patients

To evaluate the change over time of vision-related quality of life (QoL) and glaucoma symptoms in a population of newly-diagnosed primary open angle glaucoma (POAG) patients. Multicenter, prospective study. Consecutive newly-diagnosed POAG patients were enrolled and followed-up for one year. Follow-up visits were scheduled at 6 and 12 months from baseline. At each visit, vision-related QoL and glaucoma-related symptoms were assessed by the means of the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) and the Glaucoma Symptom Scale (GSS), respectively. Trends over time for NEI-VFQ-25 and GSS scores were evaluated with longitudinal linear mixed models. One-hundred seventy-eight patients were included in the analysis. At baseline, early to moderate glaucoma stages were associated with higher scores for most GSS and NEI-VFQ-25 items, while lower best-corrected visual acuity was associated with lower scores for 4 of the 12 NEI-VFQ-25 items. During the follow-up, all the GSS scores, the NEI-VFQ-25 total score, and 7 of the 12 NEI-VFQ-25 scores significantly improved (p < 0.05). In multivariate model, higher increases of most GSS and NEI-VFQ-25 scores were modeled in patients with low scores at baseline. Vision-related QoL and glaucoma-related symptom perception significantly improved during the one-year follow-up in this population of newly diagnosed POAG patients.

Chronotyping glaucoma patients with the Munich ChronoType Questionnaire: A case-control study

Purpose

The circadian clock is entrained to light by the intrinsically photosensitive retinal ganglion cells. Loss of these cells in glaucoma, an eye disease with loss of retinal ganglion cells as its key feature, might thus result in a change in chronotype. We aimed to compare the chronotype between glaucoma patients and healthy subjects.

Methods

We sent the Munich ChronoType Questionnaire to 221 glaucoma patients (response rate 81%); controls (primary control group) were primarily their spouses. After exclusion of shift workers and participants who woke-up due to an alarm clock on days off, 159 glaucoma patients (88 early, 21 moderate, 23 severe) and 163 controls remained. We calculated chronotype as the mid-sleep on days off, corrected for workweek accumulated sleep debt (MSF_sc). We compared means and variances between groups using Welch’s tests and F-tests, respectively. A secondary control group was recruited from participants in a citizen-science project (n = 17073) who completed an online questionnaire. A resampling method was applied to enable an age- and gender- matched comparison with the glaucoma patients.

Results

Compared to the primary control group, glaucoma did not affect the mean MSF_sc (controls 3:47; early, moderate, and severe glaucoma 3:40, 3:45, and 3:33, respectively [P = 0.62]). Chronotype variability seemed to increase with increasing disease severity (severe glaucoma versus controls: P = 0.023). The mean MSF_sc of the secondary control group was 3:50 (95% confidence interval 3:48 to 3:52); significantly later than that of the glaucoma patients (3:40; P = 0.024). Mean MSF_sc did not differ significantly between the control groups (P = 0.42).

Conclusions

No clear changes were found in the chronotype as determined by sleep phase in patients with glaucoma, especially not in early and moderate glaucoma. In severe glaucoma, chronotype variability seems to increase, possibly alongside a small advancement.

Factors influencing vision-related quality of life according to glaucoma severity

PURPOSE

To identify factors influencing vision-related quality of life (VRQOL) according to glaucoma severity.

METHODS

A total of 901 patients with varying stages of glaucoma were recruited from the prospectively designed LIGHT (Life Quality of Glaucoma Patients Who Underwent Treatment) study organized by the Korean Glaucoma Society. Participants completed a basic questionnaire collecting socioeconomic status and clinical information, in addition to the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25). Subjects were classified by mean deviation (MD) of integrated binocular visual field (IVF) into mild, moderate and severe damage groups. Factors were evaluated for their influence on VRQOL according to glaucoma severity using univariate and multivariable regression models between Rasch-analysed NEI VFQ-25 subscale scores and different variables.

RESULTS

The mild, moderate and severe groups contained 720, 111 and 70 patients, respectively; the mean IVF MD in each group was -1.4, -8.5 and -17.9 dB. Significant differences were observed among the three groups with respect to age, IVF MD, visual acuity (VA), education level, income level, number of glaucoma medications prescribed and follow-up period. The most influential factor associated with VRQOL according to glaucoma severity was VA. The VA of the better eye was much more influential on VRQOL than the VA of the worse eye in the moderate and severe defect groups, and the impact of VA on VRQOL was more prominent in advanced glaucoma.

CONCLUSIONS

Visual acuity is the most influential factor on VRQOL in patients with glaucoma. Preservation of VA should be strongly prioritized to maintain good VRQOL.

The Glaucoma Intensive Treatment Study (GITS), a randomized clinical trial: design, methodology and baseline data

PURPOSE

The primary objective of the ongoing Glaucoma Intensive Treatment Study (GITS) is to evaluate the effectiveness of immediate intensive treatment in comparison with the commonly recommended stepped regimen on the predicted visual field. The two treatment arms are also being compared regarding quality of life (QoL), intraocular pressure (IOP) reduction, frequency of reported side-effects, adverse events and adherence to prescribed treatment.

DESIGN

A randomized, two-centre, prospective open-labelled treatment trial for open-angle glaucoma.

PARTICIPANTS

Individuals aged 40-78 years with previously untreated and newly diagnosed glaucoma with early to moderate visual field loss were eligible.

METHODS

Patients were randomized to initial treatment either using drug monotherapy in accordance with common glaucoma guidelines or using a more intensive approach including eyedrops containing drugs from three different classes combined with 360° laser trabeculoplasty. The patients are to be followed for 5 years at visits including standard automated perimetry, optical coherence tomography (OPT) and tonometry. Change of treatment is allowed and decided upon jointly with the patient as in conventional glaucoma management.

MAIN OUTCOME

The estimated predicted preserved visual field and QoL at end of expected lifetime.

RESULTS

A total of 242 patients, 45% females, mean age 68 years, were randomized. The median untreated IOP was 24 mm Hg, and the median visual field index (VFI), indicating the percentage of a full field, was 92%.

CONCLUSION

Glaucoma Intensive Treatment Study is a clinical trial in which two groups of patients randomized to different initial intensities of IOP-reducing treatment are being compared with regard to rate of visual field progression and prediction of serious glaucomatous visual field loss at estimated at end of life.

Visual complaints of patients with glaucoma and controls under optimal and extreme luminance conditions

PURPOSE

To determine (i) whether, compared to controls, visual complaints of glaucoma patients are more pronounced under extreme luminance conditions than in the optimal luminance condition and (ii) whether complaints belonging to different extreme luminance conditions are associated.

METHODS

We developed a luminance-specific questionnaire and sent it to 221 glaucoma patients (response rate 81%); controls (182) were primarily their spouses. Median (interquartile range) mean deviation of the visual field of the patients' better eye was -4.5 (-10.7 to -1.9) dB. Questions were addressing visual performance under five luminance conditions: presumed optimal (outdoor on a cloudy day), low, high, sudden decrease and sudden increase. We compared percentages of patients and controls who reported visual complaints while performing activities under different luminance conditions.

RESULTS

Percentages of patients and controls with visual complaints were 4 versus 0% (p = 0.02) for optimal luminance and 48 versus 6% (p < 0.001), 22 versus 1% (p < 0.001), 32 versus 1% (p < 0.001) and 25 versus 3% (p < 0.001) for low, high, sudden decrease and sudden increase in luminance. Within the group of glaucoma patients, the frequency of complaints increased significantly with increasing disease severity at a Bonferroni-corrected p value of 0.003 for all but one (p = 0.005) luminance-specific questions that addressed extreme luminance conditions.

CONCLUSION

The concept of (early stage) glaucoma as an asymptomatic disease is only valid with optimal luminance. Differences in visual complaints between glaucoma patients and controls are greater under extreme luminance conditions, especially in the dark. The fact that the cases were aware of their diagnosis could have induced bias.