The Mental Peace of the Glaucoma Puzzle
I call my grandpa “nana,” and his diagnosis of glaucoma sparked my personal and professional interest in eyecare. Beyond the exam room, I have gained awareness of mental trials he’s faced moving into advanced disease.
In the realm of glaucoma, our role as providers extends past putting the various puzzle pieces that can present in glaucomatous eyes. Whether we turn to IOP lowering drops or surgical/laser procedures for treatment, our ultimate goal is to reduce the progression rate and delay possible damage to optimize functional vision as patients age.
In the realm of glaucoma, our role as providers extends past putting the various puzzle pieces that can present in glaucomatous eyes. Whether we turn to IOP lowering drops or surgical/laser procedures for treatment, our ultimate goal is to reduce the progression rate and delay possible damage to optimize functional vision as patients age.
Define the Gravity of Glaucoma
Glaucoma is the number one cause of irreversible blindness in the world. The pathophysiology of this chronic optic neuropathy is multifactorial, consisting of elevated IOP and the trabecular meshwork’s extracellular matrix dysfunction—this leads to the disruption of the lamina cribrosa, impeding axoplasmic flow to retinal ganglion cells.1,2 Consequently, reduced visual function is caused by structural damage to the optic nerve head and retinal nerve fibers.
It can be devastating when discussing a diagnosis of any chronic ocular disease that can lead to progressive and permanent vision loss. Every patient absorbs the gravity of the situation differently, based on patient education, severity of condition, or timeline of diagnosis. One aspect that is critical across the board is the mental health impact it has for our patients.
Suspect Confusion in your Glaucoma Suspects
Juggling the components that comprise a glaucoma workup and reaching a consensus of a diagnosis is a skill and an art. From the patient’s perspective, fear and confusion can clash, leaving patients stressed or overwhelmed even before they hear their confirmed diagnosis. Therefore, we should be more in tune to understanding the implications of the patient's mental health.
Effectively provide an overview by sharing the necessity for special testing as well as the required steps to reach a diagnosis. Answer questions and share that there is no need to prepare for blindness, instead clarify the significance of preparing for proactive baseline tests and consistent management to avoid risks and reduce progression of vision loss.
Effects of glaucomatous damage on quality of life
Difficulty with everyday tasks or favorite hobbies can cause frustration and cascade into limiting the patient’s confidence to perform other activities. Reduced QOL scores are associated with focal macular retinal ganglion cell and inner plexiform layer damage when compared to diffuse loss. Social and emotional psychometric factors that affect glaucoma are proven to be clinically significant.
The quality of life repercussions of functional vision loss from glaucoma was monitored with visual acuity and visual field losses in a recent study. It quantified quality of life effects, proving that the most detrimental effects were distance activities, such as driving, along with the psycho-social impact on mental health and social function.3 The chart below depicts the strong associations of QOL difficulties with visual field and visual acuity.
Early-moderate severity
Psychosocial vision loss implications occur in stages: shock or denial, anger, depression, bargaining, and acceptance.4 This sequential pattern of human emotional reactions is key to align with glaucoma’s progressive severity.
Early-moderate severity can be managed with visual fields, along with RNFL and GCC scans to monitor. GCC scans can provide better insight to early glaucoma defects that can be missed otherwise. Some tasks that patients find troublesome with early disease are reading, household work, and mobility.3 Early changes in glaucomatous vision losses can cause stress, psychological and social anxiety, and feelings of hopelessness. Considering therapy as a recommendation at early-moderate stages provides a great outlet for patients, especially in situations of possibly poor prognosis.
Advanced disease
Advanced disease has a flooring effect on RNFL scans, so series visual fields can aid monitoring. Glaucoma’s permanent vision impairments can cause loss of autonomy, social isolation, depression, anxiety, and sleep disturbances. We also know that losing your driving license can cause loss of independence, but now we can offer ride-sharing app suggestions.
Overall, the heavy reality of deteriorating vision from glaucomatous changes can lead to loss of interest in daily activities. Coping with these emotional stressors can be tough, and again, a psychiatrist or therapist referral may be indicated. Low vision rehabilitation co-management is critical and is most effective at the final psychosocial stage of acceptance.
Creative solutions to low vision challenges
The fundamental importance of low vision exams is the analysis of both objective and subjective testing, in conjunction with its effects on an individual’s quality of life, followed by implementing achievable goals to ease difficulty associated with the functional vision losses. It’s a patient-specific clinical focus for troubleshooting and mental health gauging. Better lighting, anti-glare coating, corning photochromic filters (CPF 511), and white canes for peripheral vision defects are among the creative options that are considered for vision aids.5
Small talk that provides a bigger picture
Talking to patients and learning about them is one of my favorite parts of optometry. Small talk provides a great foundation for us to get a well-rounded snapshot of the patient’s life. Not only does it show your interest in being their confidant, it also gives insight to the patient’s social world and lifestyle—aspects that may become future obstacles or solutions.
Weekend golfing with friends can become a social stressor if prognosis worsens; maybe suggest polarized glasses or discuss contrast enhancing tints like brown, amber, or rose that will aid vision on the course.
Maybe your patient is nervous about going to church with advanced loss of peripheral vision. Introduce how, with a little bit of training, their family member can be a sighted guide. You want to instill confidence so your patients have reassurance to continue activities they enjoy doing.
Goal Assessment
Ask questions and listen! Document helpful personal details in your EHR’s chart notes or special circumstances. Take note of the home setting or family members who join the exam. Are family members or friends nearby? Document the patient’s occupation, favorite hobbies, and activities as well as what they do to wind down. Whether it be cooking, reading books, watching TV, playing tennis, or jewelry making, realize all these activities have different vision demands and potential mental challenges with progressive vision loss.
All of these vision demands can be addressed with a low-vision referral. Testing visual function allows for an assessment of how to aid ease of daily activities and patient-specific goals, which is an incredible asset to patients. Not only does low vision rehabilitation provide consistent and reliable improvements in quality of life, it also gives a trustworthy connection for patients to relieve vision loss burdens.6
Providers that prepare and empower
Among other medical complications, my grandpa has no light perception in his left eye. His key goals are to have better mobility and orientation in new environments. The low vision tool that best fits him is to have his family members be his sighted guides. It makes him feel safe and properly assisted, even with a simple task we may take for granted, like getting into a car.
Understanding big picture elements, such as age and prognosis, are key to achieving the best long term outcomes of glaucoma, but it is our role as optometrists to address the accompanying emotional challenges and provide support with improving quality of life.
Suggest your recommendations of therapy and low vision referrals. Identify and amplify the areas where patients can still be independent with small adjustments. Create a sense of confidence that the patient can carry forward when they step outside of the office into their everyday life.
References
- Quigley HA. Glaucoma. The Lancet. 2011;377(9774):1367-1377. doi:10.1016/s0140-6736(10)61423-7
- Sowka J. Primary Open Angle Glaucoma. Lecture presented: 2018.
- Khachatryan N, Pistilli M, Maguire MG, et al. 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. Ophthalmic Epidemiology. 2021;28(3):265-276. doi:10.1080/09286586.2020.1863992
- Lee S. Psychosocial Aspects of Visual Impairment. Lecture presented: August 2018.
- Lee S. Contrast, Glare and Color Management with Filters and Non-optical Aids. Lecture presented: September 2018.
- Wolffsohn JS, Cochrane AL. Design of the low vision quality-of-life questionnaire (LVQOL) and measuring the outcome of low-vision rehabilitation. American Journal of Ophthalmology. 2000;130(6):793-802. doi:10.1016/s0002-9394(00)00610-3
