Depression in glaucoma patients: A review of the literature

Discussing depression in patients with visual impairment differs across countries: Validation of a prediction model in healthcare providers

PURPOSE

Healthcare providers often experience difficulties in discussing depression with adults with visual impairment (VI), obstructing timely referral. The purpose of this study was to examine predictors of routine discussions of depression with adults with VI from the perspective of different healthcare providers from different countries.

METHODS

Cross-sectional survey data from Welsh (N = 122), Australian (N = 94) and Dutch (N = 100) healthcare providers, that is eye care practitioners (ECPs) and low-vision care providers (LVCPs), were analysed. Multivariable logistic regression analysis was performed in the Welsh sample to determine predictors for discussing depression. Internal validation was conducted by using a bootstrap method, and the recalibrated model was externally validated in the Australian and Dutch sample.

RESULTS

Work experience in eye care services (OR 0.95; 95% confidence interval (CI) 0.92 to 0.99) and perceived barriers (OR 0.95; 95% CI 0.92 to 0.98) was found to predict discussing depression with patients. The area under the curve (AUC) of 0.73 reflected good discrimination of the model. The model showed a slightly better fit in the Australian sample (AUC = 0.77), but a poor fit in the Dutch sample.

CONCLUSION

The final prediction model was not generalizable to Dutch healthcare providers. They perceived less barriers in depression management than Welsh and Australian healthcare providers. This could be explained by differences in ECPs and LVCPs roles and responsibilities, increased attention on mental health and differences in organizing health care. Differences between healthcare providers' responsibilities and support needs should be taken into account while creating a facilitating environment to discuss depression.

Perspectives on Adherence to Glaucoma Medical Therapy in Brazilian Patients

BACKGROUND

Poor adherence to glaucoma medication regimens may be associated with subsequent optic nerve damage and irreversible visual loss. Specific barriers to effective patient adherence in low-middle income countries are not fully recognized and new disease-specific instruments to assess adherence have been developed.

OBJECTIVE

The purpose of this cross-sectional study was to evaluate adherence of primary open-angle glaucoma (POAG) patients to treatment in a middle-income country.

METHODS

POAG patients were recruited from the Glaucoma Service - Irmandade da Santa Casa de Misericordia de Sao Paulo, Sao Paulo, Brazil. Clinical and demographic data were retrieved from participants' electronic records. All patients answered the Glaucoma Treatment Compliance Assessment Tool (GTCAT). This 27-item questionnaire was designed to evaluate multiple behavioral factors associated with glaucoma medication adherence.

RESULTS

The sample comprised 96 patients with POAG. The mean age was 63.2 ± 8.9 years; 48 were male and 48 female; 55 (57.3%) were White, 36 (37.5%) African-Brazilian, and five (5.2 %) were of mixed color. Most patients (97.9%) had less than a high school degree and all had a family income < US$10,000. The GTCAT identified 69 (71.8%) patients who "sometimes forget to use drops," 68 (70.8%) patients who "sometimes fall asleep before dosing time," and 60 (62.5%) patients "whose drops aren't with them at the time to take them"; 82 (85.4%) patients admitted to using "reminders to take medications." Eighty-two (85.4%) patients agreed that "doctor answers my questions," and 77 (80.5%) said "they are happy with their eye doctor."

CONCLUSIONS

The GTCAT identified a number of mostly unintentional factors associated with adherence in this cohort of Brazilian patients. The data may impact on how to understand and improve adherence to ocular hypotensive treatment in the Brazilian population.

Subjective and Objective Measurement of Sleep Quality and Activity in Glaucoma

PRCIS

Glaucoma patients exhibit worse indices of sleep function by both objective and subjective metrics compared with controls.

PURPOSE

The purpose of this study is to characterize the sleep parameters and physical activity levels of glaucoma patients compared with controls.

PATIENTS AND METHODS

A total of 102 patients with a diagnosis of glaucoma in at least 1 eye and 31 control subjects were enrolled in the study. Participants completed the Pittsburgh Sleep Quality Index (PSQI) during enrollment and then wore wrist actigraphs for 7 consecutive days to characterize circadian rhythm, sleep quality, and physical activity. The primary outcomes of the study were subjective and objective metrics of sleep quality using the PSQI and actigraphy devices, respectively. The secondary outcome was physical activity, measured by the actigraphy device.

RESULTS

From the PSQI survey, glaucoma patients had higher (worse) scores compared with controls for sleep latency, sleep duration, and subjective sleep quality, whereas scores for sleep efficiency were lower (better), suggesting more time spent in bed asleep. By actigraphy, time in bed was significantly higher in glaucoma patients as was time awake after sleep onset. Interdaily stability, quantifying the synchronization to the 24-hour light-dark cycle, was lower in glaucoma patients. There were no other significant differences between glaucoma and control patients with regard to rest-activity rhythms or physical activity metrics. In contrast to the survey data, findings from the actigraphy demonstrated that there were no significant associations between the study group and controls regarding sleep efficiency, onset latency, or total sleep time.

CONCLUSIONS

In this study, patients with glaucoma demonstrated several subjective and objective differences in sleep function when compared with controls, whereas physical activity metrics were similar.

Topiramate-Induced Aqueous Misdirection in a Nanophthalmic Eye

A 51-year-old female was referred to the emergency department with a one-day history of severe right eye pain, blurry vision, and conjunctival injection. A review of past ocular history was notable for nanophthalmos and narrow angles with patent peripheral iridotomies. Anterior segment exam findings were consistent with aqueous misdirection and a review of medications indicated recent topiramate initiation for headaches and depression. The acute attack was initially controlled with medical management and plans for future surgical intervention were made. Although ocular screening prior to initiation of topiramate is not recommended, this case highlights the importance of pre-screening in a patient with a pre-existing condition such as nanophthalmos. Additionally, this case addresses the ocular side effects of anti-depressants and the emerging relationship between glaucoma and depression. Appropriately addressing these issues and coordinating care with behavioral health providers has the potential to prevent optic nerve damage and loss of vision.

Depression secondary to vision loss in old age and an effective rapid screening tool for undiagnosed cases

BACKGROUND

Zenebe et al. recently stated that despite depression being a common mental health problem in the elderly population, it is underdiagnosed in over half of the cases (Zenebe et al. in Ann Gen Psychiatry, 2021). They described an extensive list of risk factors associated with geriatric depression. However, we noted that they did not include ophthalmic conditions in this list which have previously been identified as an important risk factor for depression in the elderly.

MAIN BODY

To determine the extent of undiagnosed anxiety and depression in our elderly population with vision loss, we screened a cohort of our patients, over 60 years with vision loss secondary to macular disease for both conditions. Our cohort included 104 patients with mean best corrected visual acuity 0.58 LogMAR (Snellen equivalent 6/24). In this group, we identified 29.8% (31/104) and 28.8% (30/104) of patients with at least one depression or anxiety-related symptom, respectively, in the past 2 weeks. We identified 7.7% (8/104) and 3.8% (4/104) who had significant symptoms of depression and anxiety, respectively, that warranted further follow-up. Only two of these patients had previously been diagnosed with anxiety or depression with the majority having no previous history of either condition. Patients from our cohort who screened for depression or anxiety often cited frustration completing tasks and loss of independence secondary to declining vision. They also complained that the vision loss resulted in a lack of confidence which in turn resulted in social isolation and loneliness. Most of the patients welcomed referral to their GP for follow-up for input regarding their mental health and they also stated an interest in attending hospital optometry low vision services and counselling support.

CONCLUSIONS

With increasing time pressures on healthcare services and the rising use of virtual clinics especially during the COVID-19 pandemic, it is still essential to screen efficiently for depression in those elderly patients who are at significant risk. There is a considerable burden of major depressive disease in the geriatric population, and we would recommend that physicians (Geriatricians, GPs, Ophthalmologists etc.) screen elderly patients with vision loss for depression using the rapid screening tool which we suggest.