Association of Psychosocial Factors with Activation Among Patients with Glaucoma.

OBJECTIVE: To investigate the association of psychosocial factors with health self-management behaviors and beliefs among patients with primary open-angle glaucoma (POAG). DESIGN: Prospective cross-sectional cohort study. PARTICIPANTS: Patients (n = 202) with mild, moderate, or advanced bilateral POAG. METHODS: Patients (N = 1164) were identified from electronic medical records at a single academic medical center. Letters soliciting participation were mailed to 591 randomly selected potential participants. Psychometric measures and a social determinants of health questionnaire were administered by phone to 202 study participants. MAIN OUTCOME MEASURES: The National Eye Institute Visual Function Questionnaire-8 (NEI-VFQ), the Multidimensional Health Locus of Control (MHLC), the Perceived Medical Condition Self-Management Scale-4, the Patient Health Questionnaire-9 (PHQ), the Patient Activation Measure-13 (PAM), a health literacy question, and a social determinants of health questionnaire. RESULTS: For each increase in level of POAG severity, there was a decrease in mean NEI-VFQ score (P < 0.001). For each unit increase in NEI-VFQ item 1, self-rated vision, mean PAM score increased (R2 = 5.3%; P = 0.001; 95% confidence interval [CI], 0.077-0.276). For each unit increase in "Internal" on the MHLC, mean PAM score increased (R2 = 19.3%; 95% CI, 0.649-1.166; P < 0.001). For each unit increase in "Doctors" on the MHLC, mean PAM score increased (R2 = 11.0%; 95% CI, 1.555-3.606; P < 0.001). For each unit increase in "Chance" on the MHLC, mean PAM score decreased (R2 = 2.6%; 95% CI, -0.664 to -0.051; P = 0.023). On multivariate analysis, adjusting for age, sex and race, for each unit increase in PHQ, mean PAM score decreased (95% CI, 0.061-1.35; P = 0.032); for each unit increase in MHLC "Doctors", mean PAM score increased (95% CI, -1.448 to 3.453; P < 0.001); for each unit increase in MHLC "Internal", mean PAM score increased (95% CI, 0.639-1.137; P < 0.001); for each unit increase in MHLC "Chance", mean PAM score decreased (95% CI, -0.685 to -0.098; P = 0.009). CONCLUSIONS: We identified modifiable behavioral factors that could increase patients' self-perceived ability and confidence to manage their own eye care. Locus of control (MHLC), level of depression (PHQ), and self-rated functional vision (NEI-VFQ) were each associated with patient behaviors, attitudes, and beliefs needed for health self-management (activation, assessed by the PAM) and may be important determinants of adherence behaviors. Targeting change in patients' care beliefs and behaviors may improve activation and treatment outcomes. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Primary trabeculectomy for advanced glaucoma: pragmatic multicentre randomised controlled trial (TAGS).

OBJECTIVE: To determine whether primary trabeculectomy or primary medical treatment produces better outcomes in term of quality of life, clinical effectiveness, and safety in patients presenting with advanced glaucoma. DESIGN: Pragmatic multicentre randomised controlled trial. SETTING: 27 secondary care glaucoma departments in the UK. PARTICIPANTS: 453 adults presenting with newly diagnosed advanced open angle glaucoma in at least one eye (Hodapp classification) between 3 June 2014 and 31 May 2017. INTERVENTIONS: Mitomycin C augmented trabeculectomy (n=227) and escalating medical management with intraocular pressure reducing drops (n=226) MAIN OUTCOME MEASURES: Primary outcome: vision specific quality of life measured with Visual Function Questionnaire-25 (VFQ-25) at 24 months. SECONDARY OUTCOMES: general health status, glaucoma related quality of life, clinical effectiveness (intraocular pressure, visual field, visual acuity), and safety. RESULTS: At 24 months, the mean VFQ-25 scores in the trabeculectomy and medical arms were 85.4 (SD 13.8) and 84.5 (16.3), respectively (mean difference 1.06, 95% confidence interval -1.32 to 3.43; P=0.38). Mean intraocular pressure was 12.4 (SD 4.7) mm Hg for trabeculectomy and 15.1 (4.8) mm Hg for medical management (mean difference -2.8 (-3.8 to -1.7) mm Hg; P<0.001). Adverse events occurred in 88 (39%) patients in the trabeculectomy arm and 100 (44%) in the medical management arm (relative risk 0.88, 95% confidence interval 0.66 to 1.17; P=0.37). Serious side effects were rare. CONCLUSION: Primary trabeculectomy had similar quality of life and safety outcomes and achieved a lower intraocular pressure compared with primary medication. TRIAL REGISTRATION: Health Technology Assessment (NIHR-HTA) Programme (project number: 12/35/38). ISRCTN registry: ISRCTN56878850.

Assessment of Depression, Anxiety, and Quality of Life in Singaporean Patients With Glaucoma.

PURPOSE: To determine the prevalence and risk factors for anxiety disorder and depression among glaucoma patients in Singapore, and to assess the relationship between quality of life (QOL) and depression/anxiety. METHODS: In this cross-sectional study, glaucoma patients aged 21 and above with a known diagnosis of primary open-angle glaucoma or primary angle-closure glaucoma were recruited from a tertiary care hospital. Patients with other types of glaucoma, and coexisting ocular or psychiatric disorders were excluded.Ophthalmic examination was carried out on all participants, which included best-corrected visual acuity (BCVA), intraocular pressure (IOP), gonioscopy, standard automated perimetry, and optic disc evaluation. Sociodemographic information and treatment histories were also collected.The Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), and Visual Function Questionnaire (VFQ25) were administered to evaluate for depression, anxiety, and impact on QOL, respectively. RESULTS: A total of 100 patients were included in this study. The mean age was 67.1±12.0 years (range, 24 to 90 y). The frequency of depression and anxiety among our patients was 30% and 64%, respectively. The mean HAM-D score was 4.37±4.17 (range, 0 to 17), whereas the mean HAM-A score was 2.38±2.80 (range, 0 to 13). The mean VFQ25 score was 78.8±16.0 (range, 42.4 to 97.0). The poorest subscale on the VFQ25 was driving, with a mean score of 42.4±42.6 (range, 0.0 to 100.0).We did not find any significant difference between the presence of depression/anxiety between patients with primary open-angle glaucoma (P=0.263) and primary angle-closure glaucoma (P=0.830). Risk factors for depression included: female sex (P=0.020), higher logMAR BCVA in the worse eye (P=0.004), higher cup-disc ratio (P=0.016), lower MD in the better and worse eye (P=0.022 and 0.001, respectively), and lower mean VFQ25 score (P<0.001). Risk factors for anxiety included: lower MD in the worse eye (P=0.004) and lower mean VFQ25 score (P=0.004). There was also no significant association between the use of topical ß-blockers/carbonic anhydrase inhibitors with depression (P=0.793) or anxiety (P=0.282). CONCLUSIONS: There is a relatively high prevalence of depression (30%) and anxiety disorders (64%) among glaucoma patients in Singapore. Female glaucoma patients are more likely to suffer from depression. Other risk factors for depression include higher cup-disc ratio, higher logMAR BCVA, lower MD, and a lower mean VFQ25 score. Risk factors for anxiety disorder include lower MD and lower mean VFQ25 score. Ophthalmologists could consider use of the VFQ25 as an assessment for impairments in QOL in a glaucoma patient. If a glaucoma patient is at high risk of depression or anxiety disorder, a multidisciplinary management approach involving ophthalmology and psychiatry may be required.

Psychometric properties of the Glaucoma Treatment Compliance Assessment Tool in a multicenter trial.

PURPOSE: To assess the psychometric properties of a new version of the Glaucoma Treatment Compliance Assessment Tool, a survey evaluating health behavior and glaucoma adherence using constructs from the Health Belief Model. DESIGN: Psychometric analysis. METHODS: We administered the 47-statement Glaucoma Treatment Compliance Assessment Tool to 201 participants who were using a single bottle of an ocular hypotensive agent, and objectively measured adherence with medication event monitoring system devices over 60 days. Adherence was the percentage of days with correctly timed bottle openings. We used principal components analysis to determine construct validity, Cronbach's alpha for internal consistency reliability, frequency analysis for floor and ceiling effects, and Spearman rho for test-retest reliability. We determined predictive validity using univariate and multiple regression. RESULTS: The mean (±SD, range) adherence percentage was 79.9% (±18.5%, 20.3%-100.0%). Principal component analysis loaded 24 questions into 6 components that were consistent with the Health Belief Model. All 6 components had Cronbach's alpha reliability between 0.601 and 0.797. No statements had floor or ceiling effects, and all statements had acceptable test-retest reliability. Multiple regression analysis showed 4 Health Belief Model statements, white race, older age, and married marital status to be associated with higher adherence (adjusted R(2) = 0.27, P < .001). CONCLUSIONS: The newest version of the Glaucoma Treatment Compliance Assessment Tool showed acceptable psychometric properties. With further refinement, clinicians and researchers could use it to examine factors related to adherence and measure improvement in adherence with a change in health behavior attitudes.

Assessment of the vision-specific quality of life using clustered visual field in glaucoma patients.

PURPOSE: To investigate the significance of vision-specific quality of life (QOL) in glaucoma patients based on the location of visual field defects. PATIENTS AND METHODS: We examined 336 eyes of 168 patients. The 25-item National Eye Institute Visual Function Questionnaire was used to evaluate patients' QOL. Visual field testing was performed using the Humphrey Field Analyzer; the visual field was divided into 10 clusters. We defined the eye with better mean deviation as the better eye and the fellow eye as the worse eye. A single linear regression analysis was applied to assess the significance of the relationship between QOL and the clustered visual field. RESULTS: The strongest correlation was observed in the lower paracentral visual field in the better eye. The lower peripheral visual field in the better eye also showed a good correlation. Correlation coefficients in the better eye were generally higher than those in the worse eye. For driving, the upper temporal visual field in the better eye was the most strongly correlated (r=0.509). For role limitation and peripheral vision, the lower peripheral visual field in the better eye had the highest correlation coefficients at 0.459 and 0.425, respectively. CONCLUSIONS: Overall, clusters in the lower hemifield in the better eye were more strongly correlated with QOL than those in the worse eye. In particular, the lower paracentral visual field in the better eye was correlated most strongly of all. Driving, however, strongly correlated with the upper hemifield in the better eye.

Depression and quality of life in patients with glaucoma: a cross-sectional analysis using the Geriatric Depression Scale-15, assessment of function related to vision, and the Glaucoma Quality of Life-15.

PURPOSE: To determine the prevalence of depression and its association with visual field impairment, quality of life, objective assessment of visual function, and glaucoma severity in elderly patients with glaucoma. DESIGN: Cross-sectional study. PARTICIPANTS AND CONTROLS: One hundred sixty-five patients with mild (n=60), moderate (n=43), or severe (n=28) glaucoma and 34 controls with ocular hypertension were enrolled. Severity was stratified according to the Nelson Glaucoma Severity Scale (based on the degree of binocular visual field loss). Groups were substratified according to age. METHODS: Demographic information was collected via interviews; the Geriatric Depression Scale-15 and Glaucoma Quality of Life-15 (GQL-15) questionnaires were administered. Visual function was assessed by clinical examination and visual field testing. A subset of patients (n=68) underwent objective assessment of function related to vision. Group differences were evaluated using analysis of variance; Kruskall-Wallis analysis of ranks was performed with significance set at P<0.05. Age-adjustment of P values was performed using analysis of covariance for parametric data and Kruskall-Wallis analysis on age-stratified nonparametric data. A binary univariate regression analysis modeled depression to suspected risk factors. Significant predictive variables were modeled in a multivariate regression analysis. RESULTS: Depression was more prevalent with increasing glaucoma severity, reaching statistical significance in patients aged 70 to 79 years (P<0.02). Summary and subfactor GQL-15 scores reflected decreased quality of life with increasing glaucoma severity. Assessment of function related to vision scores indicated worsening visual function with increasing glaucoma severity. On multivariate regression analysis, depression status was correlated with age and GQL-15 summary score. CONCLUSIONS: Depression is more common in patients with increasing glaucoma severity (age, 70 to 79 y). In patients with glaucoma or ocular hypertension, age and GQL-15 summary score are independent risk factors for depression.

Assessment of contrast gain signature in inferred magnocellular and parvocellular pathways in patients with glaucoma.

PURPOSE: Contrast gain signatures of inferred magnocellular and parvocellular postreceptoral pathways were assessed for patients with glaucoma using a contrast discrimination paradigm developed by Pokorny and Smith. The potential causes for changes in contrast gain signature were investigated using model simulations of ganglion cell contrast responses. METHODS: Foveal contrast discrimination thresholds were measured with a pedestal-Delta-pedestal paradigm developed by Pokorny and Smith [Pokorny, J., & Smith, V. C. (1997). Psychophysical signatures associated with magnocellular and parvocellular pathway contrast gain. Journal of the Optical Society of America A, 14(9), 2477-2486]. Stimuli were 27 ms luminance increments superimposed on 227 ms pulsed Delta-pedestals. Contrast thresholds and contrast gain signatures mediated by the inferred magnocellular (MC) and parvocellular (PC) pathways were assessed using linear fits to contrast discrimination thresholds at either lower or higher Delta-pedestal contrasts, respectively. Twenty-seven patients with glaucoma were tested, as well as 16 age-similar control subjects free of eye disease. RESULTS: Contrast sensitivity and contrast gain signature mediated by the inferred MC pathway were lower for the glaucoma group, and reduced contrast gain signature was correlated with reduced contrast sensitivity (r(2)=45%, p<.0005). These two parameters mediated by the inferred PC pathway were little affected for the glaucoma group. Model simulations suggest that the reduced contrast sensitivity and contrast gain signature were consistent with the hypothesis that reduced MC ganglion cell dendritic complexity can lead to reduced effective retinal illuminance, and hence increased semi-saturation contrast of the ganglion cell contrast response functions. CONCLUSIONS: The contrast sensitivity and contrast gain signature of the inferred MC pathway were reduced in patients with glaucoma. The results were consistent with a model of ganglion cell dysfunction due to reduced synaptic density.

Assessment of function related to vision (AFREV).

OBJECTIVES: To evaluate the relationship of a performance-based measure of visual functioning to clinical and subjective measures in glaucoma patients. DESIGN: Cross-sectional survey of glaucoma patients. PARTICIPANTS: Forty-three patients with primary open-angle glaucoma. METHODS: Patients were evaluated using a novel performance-based measure, the Assessment of Function Related to Vision (AFREV), standard clinical tests of visual function, and the National Eye Institute's Visual Functioning Questionnaire (NEI-VFQ-25), a self-reported quality of life measure. Correlations of the AFREV scores with visual field scores, monocular and binocular visual acuity, contrast sensitivity scores, and NEI-VFQ scores were calculated. Rasch analysis was used to estimate the visual ability required by each task of AFREV for a particular response (item measures) and to estimate the visual ability of each patient (person measures). MAIN OUTCOME MEASURES: AFREV and NEI-VFQ total scores. RESULTS: The AFREV total scores were highly correlated with contrast sensitivity (r = 0.772), binocular visual acuity (r = -0.768), better-eye visual acuity (r = -0.737), worse-eye visual acuity (r = -0.675), and Estermann visual field efficiency scores (r = 0.606) as well as with NEI-VFQ scores (r = 0.70). The resulting index, constructed from 5 items of the AFREV, is unidimensional, thereby satisfying the primary assumption of the Rasch model. The Rasch person-item map demonstrates that the "putting stick into holes" and "reading small print" tests require the most visual ability. CONCLUSIONS: The AFREV performance-based measure, a new test of a spectrum of activities, correlates well with some standard measures of visual function and certain aspects of self-report assessments. AFREV appears to be a valid measure of performance ability that may provide information not obtainable from standard measures of visual function or subjective surveys.

Utility values in Singapore Chinese adults with primary open-angle and primary angle-closure glaucoma.

PURPOSE: To evaluate utility values in Chinese glaucoma patients. PATIENT AND METHODS: Singapore Chinese residents (n = 213) with primary open-angle glaucoma or primary angle-closure glaucoma were recruited from a single tertiary ophthalmic center. Standard face-to-face interviews were conducted to ask about utility values (time trade-off and standard gamble for both death and blindness). Ocular information, including current visual acuity, intraocular pressure, visual field defect, and cup-disc ratio were also obtained. RESULTS: The mean time trade-off utility value was 0.88 (95% confidence interval 0.85, 0.91), and standard gamble for death and blindness were 0.94 (95% confidence interval 0.93, 0.96) and 0.95 (95% confidence interval 0.93, 0.97), respectively. Only 35.7% of patients were willing to trade time, and 34.3% willing to risk blindness in return for perfect vision. Both primary angle-closure glaucoma and primary open-angle glaucoma patients had similar utility values. After adjusting for age, gender, language spoken, educational level, and diagnosis, patients with better eye visual field PSD > 10 were 2.52 times (95% confidence interval 1.13, 5.61) more willing to trade time. In a multivariate model, the odds ratio of willingness to risk blindness for a complete hypothetical glaucoma cure was 9.88 (95% confidence interval 1.65, 59.23) for patients who had only visited an ophthalmologist 15 years or more ago, and 0.53 (95% confidence interval 0.27, 1.02) for patients who had previous trabeculectomy. CONCLUSION: Most Chinese glaucoma patients in Singapore are not willing to trade time or risk blindness. Patients with worse visual fields in the better-seeing eye are more willing to trade time; whereas patients who have not seen an ophthalmologist for at least 15 years or who had no history of a previous trabeculectomy are more willing to risk blindness.

Personality assessment based on the five-factor model of personality structure in patients with primary open-angle glaucoma.

PURPOSE: Several characteristic personality types have been reported for glaucoma patients in previous studies. However, none of the previous studies used a common structural theory of personality. In this study, we conducted a multicenter cross-sectional case-control study using the recently established five-factor model of personality structure. METHODS: Personality was evaluated using the Neuroticism Extraversion Openness Five-Factor Inventory (NEO-FFI), which is a questionnaire specifically designed to test the five-factor model of personality: neuroticism (N), extraversion (E), openness (O), agreeableness (A), and conscientiousness (C). Eligible questionnaires were obtained from 196 patients with primary open-angle glaucoma (POAG) (99 men, 97 women) and 223 reference subjects with no ocular disease except cataract (87 men, 136 women). The mean score of each NEO-FFI factor for POAG patients was compared to the scores for the reference subjects. RESULTS: Compared with the reference subjects, the mean N score was significantly higher (P = 0.013), the mean scores for A and C were significantly lower (P = 0.007 and P = 0.001, respectively), and the mean E score tended to be lower (P = 0.055) in male POAG patients. The mean E score was significantly lower (P = 0.023) in female POAG patients. CONCLUSIONS: Characteristic personality traits were noted in POAG patients, and a more significant relationship was found between personality and glaucoma in men than in women.