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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 33  |  Issue : 2  |  Page : 167-172

Relationship among standard vision tests, quality of life, and ability to do daily activities in patients with glaucoma


Department of Ophthalmology, Government Medical College, Thrissur, Kerala, India

Date of Submission23-Oct-2020
Date of Decision11-Nov-2020
Date of Acceptance12-Nov-2020
Date of Web Publication21-Aug-2021

Correspondence Address:
Dr. Neethu Pradeep
Department of Ophthalmology, Government Medical College, Thrissur, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_163_20

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  Abstract 


Background and Objectives: (1) To assess the quality of life (QoL) in patients with glaucoma by (a) clinical assessment, (b) subjective (Visual Functioning Questionnaire-25 [VFQ-25]), and (c) objective (Assessment of Disability Related to Vision [ADREV]) tests and (2) to find out the relationship between glaucoma stages and QoL. Materials and Methods: This cross-sectional study includes 100 patients attending the glaucoma clinic of a tertiary institution in Kerala. Best-corrected visual acuity, baseline intraocular pressure, slit-lamp and fundus examination, gonioscopy, and visual field examination were carried out. Patients were categorized as early, moderate, and advanced on the basis of disc damage likelihood scale (DDLS) and modified Hodapp–Parrish–Anderson criteria. QoL was assessed subjectively using VFQ-25 and objectively by ADREV test by assessing the ability to perform activities of daily living. Contrast sensitivity and stereopsis were the other parameters assessed. Results: Of the 100 patients, 50 (50%) were POAG, 46 (46%) were PACG, and 4 were secondary glaucoma. Based on the DDLS and Anderson criteria, there were 33 early, 34 moderate, and 33 advanced glaucoma cases. The mean ADREV/VFQ scores were as follows: early, 56.9/81.1; moderate, 54.9/75; and advanced, 45.8/52.6. In ADREV tasks, the lowest mean score was for motion detection (5.1) and maximum score was for ambulation (6.1) in the study population. Patients with advanced glaucoma have difficulty in detecting motion (4.1), recognizing street signs (4.3), and color matching (4.8). Stereopsis was seen in 60% of patients with early, 29% of moderate, and 6% of advanced glaucoma. Contrast sensitivity was also reduced with glaucoma progression. Conclusion: ADREV (objective) scores correlate significantly with VFQ (subjective) scores in all the three categories of glaucoma. ADREV (objective test) scores correlate better with the severity and stages of glaucoma and degree of impairment patients experience than VFQ-25 (subjective test). With respect to QoL, patients with glaucoma faced difficulty in performing fine tasks. However, even advanced glaucoma cases were able to carry out their daily activities without much help. Stereopsis and contrast sensitivity were the most affected with advancement of disease.

Keywords: Assessment of Disability Related to Vision, contrast sensitivity, disc damage likelihood scale, glaucoma, Hodapp–Parrish–Anderson, quality of life, stereopsis, Visual Functioning Questionnaire-25


How to cite this article:
Pradeep N, Narayan S, Sujatha N, Thulaseedharan S, Sudha V. Relationship among standard vision tests, quality of life, and ability to do daily activities in patients with glaucoma. Kerala J Ophthalmol 2021;33:167-72

How to cite this URL:
Pradeep N, Narayan S, Sujatha N, Thulaseedharan S, Sudha V. Relationship among standard vision tests, quality of life, and ability to do daily activities in patients with glaucoma. Kerala J Ophthalmol [serial online] 2021 [cited 2021 Nov 30];33:167-72. Available from: http://www.kjophthal.com/text.asp?2021/33/2/167/324219




  Introduction Top


Glaucoma is a chronic progressive optic neuropathy characterized by loss of retinal nerve fiber layer, recognized clinically as loss of neuroretinal rim, and visual field defects.[1] For most patients, having sufficient vision to perform their daily activities is a high priority. Understanding this aspect of a disease is provided by tests evaluating quality of life (QoL).

Glaucoma may affect a patient's QoL in several ways such as the psychological effects arising from the fear of blindness leading to anxiety and depression, decreased visual field and ultimately visual acuity, the potential side effects of treatment, and the economic burden due to the cost of visits and therapy and loss of income because of absenteeism from work.

The clinician performs a battery of tests to assess the structure of the optic disc and its function, correlates them, based on which he/she decides on the stage of severity of glaucoma, and advises treatment to prevent its progression. The ultimate goal of glaucoma management is the preservation of patient's visual function and QoL. This complicated clinical perspective is difficult for the patient to understand.

Indicating to a patient, a functional deficit in an activity of daily living would be expected to have a more powerful impact than commenting on a concern regarding intraocular pressure (IOP) or change in visual field. When patients understand their disease better, they take better care of themselves. The goal of the treatment of patients with glaucoma is to prevent disability or, if disability already exists, to repair the disability or at the least to prevent further disability from developing. Hence, the ultimate goal in the management of glaucoma is maintenance of QoL through preservation of vision. However, very often, this becomes secondary to assessment of IOP, visual field changes, and optic disc appearance.

The National Eye Institute (NEI)–Visual Function Questionnaire (VFQ)-25 describes the patient's satisfaction with his/her visual function and how visual ability impacts his/her life.[2],[3] A better understanding of this NEI-VFQ-25 questionnaire can improve the patient–physician interaction.

The various tasks that are affected at various stages of the disease can also be objectively assessed by the Assessment of Disability Related to Vision (ADREV).[4] This performance-based assessment is also validated and easily reproducible.

Although each approach provides a unique and important perspective in understanding the lives of patients with glaucoma, studies that integrate all the three methods are very few and have not been done in India. The purpose of our study is to assess the strength of relationship between clinical, subjective, and objective measures of visual function in glaucoma. Hence, the current study aims to have a broader look on glaucoma and its treatment by assessing the QoL. It also helps plan our treatment strategies wisely, so that patients QoL is given equal importance along with the medical and surgical management.


  Materials and Methods Top


A cross-sectional observational study was done on 200 eyes of 100 patients with glaucoma who attended the glaucoma clinic of a tertiary institution in Kerala. The institutional ethics committee and institutional review board approved this study. The first 100 consecutive patients previously diagnosed and undergoing treatment for glaucoma were selected for the study.

Individuals with neurological or musculoskeletal problems that would influence their performance in different tests in the study, any medical condition that would preclude the subject from providing reliable or valid data, incisional eye surgery within the past 3 months, and visual impairment due to other causes were excluded from the study.

Each patient underwent a complete ophthalmic work up including history,best corrected visual acuity,slit lamp examination and a dilated fundus examination using an indirect ophthalmoscope.They also underwent a complete glaucoma workup including Goldmann applanation tonometry,gonioscopy,optic disc and retinal nerve fibre layer evaluation using 90 D lens by slitlamp biomicroscopy.

Patients were categorized on the basis of disc damage likelihood scale (DDLS)[5] and modified Hodapp–Parrish–Anderson (HPA) criteria[6] into three groups:

  1. Group 1: Early (early glaucomatous loss (MD < 6DB) with DDLS Stage 1–4 in both eyes)
  2. Group 2: Moderate (moderate glaucomatous loss with DDLS Stage 1–4/5–7 in better eye and 5–7/8–10 in worst eye)
  3. Group 3: Advanced (advanced glaucomatous loss with DDLS Stage 8–10 in both eyes).


Standard methods of visual function testing including visual acuity, stereopsis using stereo fly test, visual field testing using Humphrey's field analyzer, and contrast sensitivity using Pelli Robson chart were done.

A validated Malayalam translation of the NEI-VFQ-25 was explained to the patients, and their response was recorded. All questions in NEI-VFQ-25, except two (related to parameter “driving”), were included in this study. The total score of VFQ-25 was calculated according to the guidelines in NEI-VFQ-25 scoring algorithm. Patients were also assessed for the performance of daily activities using ADREV.

Tasks included in ADREV are performed by the patient in the following order.

  1. Reading in reduced illumination
  2. Recognizing facial expression
  3. Detecting motion
  4. Recognizing street sign
  5. Locating objects
  6. Ambulating
  7. Placing peg into different sized holes
  8. Telephoning
  9. Matching socks.


The tasks were performed with both eyes viewing and wearing their present habitual refractive correction. Tasks such as reading in reduced illumination, recognizing facial expression, and detecting motion test were carried out in a dark room, and the rest of the tasks were done in ambient lighting. Statistical analysis was performed using SPSS 21.0 version (Statistical Package for the Social Sciences 21.0 version). Pearson's correlation test was used for calculating correlation coefficient. Differences were considered statistically significant when the P value was 0.01 or less.


  Results Top


The study population consisted of 100 patients with glaucoma aged between 35 and 75 years who attended the glaucoma clinic.

Based on the DDLS and HPA criteria, the study patients were divided into three groups:

  1. Group 1: Early (early glaucomatous loss [MD <6 DB] with DDLS Stage 1–4 in both eyes)
  2. Group 2: Moderate (moderate glaucomatous loss with DDLS Stage 1–4/5–7 in better eye and 5–7/8–10 in worst eye)
  3. Group 3: Advanced (advanced glaucomatous loss with DDLS Stage 8–10 in both eyes.


The number of patients in each group is shown in [Figure 1]. Majority of the patients were between 55 and 75 years in the study population. In the individual groups, the mean age of all the patients was comparable [Figure 2]. However, the mean age of patients with early glaucoma was low compared to the moderate and advanced cases. Gender proportion was comparable in the present study. There were about 59 males and 41 females in the study. The number of cases of primary open angle (50) and angle closure (46) was almost equal. There were four secondary glaucoma cases, out of which two were pseudoexfoliative glaucoma, one angle recession glaucoma, and one combined mechanism glaucoma.
Figure 1: Number of patients in each group

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Figure 2: Mean age of individual group

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Clinical characteristics of the study population

The clinical characteristics of the study population are shown in [Table 1]. In 100 patients, the mean visual acuity was found to be 0.269. The total VFQ score was in the range of 13.4–94.7. The mean score was found to be 69.6. When considering the ADREV scores, the maximum score obtained was 63 and the minimum was 31. The mean ADREV score was 52.5. The contrast sensitivity also showed a wide range. The maximum value obtained was 2.25, 0.15 being the minimum score. As far as stereopsis is concerned, it was seen in only 32 patients.
Table 1: Clinical characteristics of study population

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Assessment of Disability Related to Vision versus Visual Functioning Questionnaire

The mean ADREV versus VFQ scores [Figure 3] are as follows:
Figure 3: Comparison of subjective and objective scores

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  1. Group 1 (early) – 56.9/81.1
  2. Group 2 (moderate) – 54.9/75
  3. Group 3 (advanced) – 45.8/52.6.


There is a proportionate decrease in both the scores in the study population with respect to the severity of glaucoma.

Stereopsis

Stereopsis was seen to be grossly affected with glaucoma progression. In patients with advanced glaucoma, only two people had gross stereopsis [Figure 4].
Figure 4: Stereopsis of the study population

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Contrast sensitivity

Contrast sensitivity in the entire study population ranges from 0.15 to 2.25. The mean contrast sensitivity of patients with early glaucoma was about 1.22, whereas in advanced glaucoma, the mean has reduced drastically to 0.58. Contrast sensitivity also showed a declining trend with glaucoma progression [Figure 5]. Even in patients with early glaucoma, contrast sensitivity is comparatively low when compared to the normal population. Patients with advanced glaucoma have very low contrast sensitivity, which can adversely affect their QoL.
Figure 5: Contrast sensitivity of the study population

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Assessment of Disability Related to Vision individual tasks

Patients with early glaucoma scored reasonably good for all the tasks except motion detection. Moderate glaucoma cases also had difficulty in detecting motion and recognizing street signs. In advanced glaucoma, tasks such as motion detection, street sign recognition, and matching colors had very low scores. Detecting motion was the task that was difficult for all the three categories of glaucoma. Even the advanced glaucoma cases had a fairly good score for ambulation. Reading and recognizing facial expression and ambulation were the tasks that the patients with advanced glaucoma performed well [Figure 6].
Figure 6: Individual Assessment of Disability Related to Vision scores of various groups

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Correlation among the study variables

There was a strong positive correlation of 0.78 (P < 0.01) between ADREV (objective) and VFQ scores (subjective) [Table 2]. DDLS showed a higher correlation coefficient for ADREV (objective) (r = −0.61, P < 0.01) than VFQ (r = −0.54, P < 0.01). Visual acuity had a higher correlation with ADREV than VFQ scores. Contrast sensitivity score showed a moderate correlation with both ADREV (r = 0.53, P < 0.01) and VFQ (r = 0.58, P < 0.01).
Table 2: Correlation among study variables

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  Discussion Top


The awareness of the correlation between clinical assessment of visual function and QoL has prompted new approaches to the management of glaucoma. Clinical trials strongly suggest that changes in QoL should be the key outcome measure of treatment.

In the present study, the mean age of the study population varies from 35 to 75 years. Majority were in the age group of between 55 and 75 years. The prevalence of glaucoma increases with advancing age.[7] Our study also showed an increased prevalence with age.

Out of 100 patients, there were 41 females and 59 males. In our study, there was not much significant prevalence by gender. Women are at higher risks for angle-closure glaucoma, but there is no clear gender predilection for open-angle glaucoma.[8] In our study, also, majority of the angle-closure glaucoma cases were female. In the current study, in addition to the routine clinical assessment, we asked the patients about their QoL and we observed how patients with glaucoma actually function.

Assessment of Disability Related to Vision versus Visual Functioning Questionnaire

There was a statistically significant correlation between the total scores of ADREV and the NEI-VFQ-25 and between domains of the NEI-VFQ-25 and related ADREV tasks as per the study by Lorenzana et al.[9] Our study also showed a significant correlation between subjective (NEI-VFQ-25) and objective (ADREV) tests.

Clinical assessment versus Assessment of Disability Related to Vision versus Visual Functioning Questionnaire

The total ADREV score showed a more correlation with various clinical assessment test than the NEI-VFQ. This was similar to a study conducted by Richman et al.[10] The total ADREV score provides more accurate representation of disease severity, in terms of functional ability, than the total NEI-VFQ-25 score.

There are several possible explanations for the lack of concordance between the clinical and subjective tests. Self-reports are based on patient's understanding of what the presented task might involve, their assessment of the task's relative difficulty, and their own perceptions of their ability to perform that task. Performance-based testing removes this subjectivity and simply involves observing a patient's actual ability to perform a given task.

There are several discrepancies between self-report and performance-based measures in our study similar to studies by Viswanathan et al.,[11] Friedman et al.,[12] and Kempen et al. Subjects with the same severity of disease clinically had more variation in their responses to QoL questions than the amount of variation in how they performed the tasks of daily living in our study. This is to be expected, because QoL is influenced by a wide variety of components; more involved are ability such as detecting motion.

Assessment of Disability Related to Vision tasks

The tasks are designed in such a way that they simulate the existing environment of the subjects. When performing the tasks, they could relate that to real situations in life. Even though we expect a tubular vision in advanced glaucoma, most of the patients were able to carry out daily activities such as ambulating, searching objects, reading, and recognizing easily. However, when it comes to fine activities such as telephoning, color matching, street sign recognition, and motion recognition, they are facing difficulty.

By performing the ADREV tasks, it becomes easy for the clinician as well as patient to assess the abilities and disabilities. It makes them aware of their capabilities, and at the same time, it warns them about their weakness. This helps in their lifestyle modification and thereby improving their QoL. Motion detection and street sign recognition were the parameters that were affected in all the three categories of glaucoma. Studies conducted by Richman and Spaeth et al. also showed the lowest score for motion detection.[10]

In a study conducted by Lin JC et al., most patients could walk without difficulty (76.4%), take care of themselves (89.6%), and manage activities of daily living without assistance (79.9%).[13] Our study also obtained similar results. The scores of individual tasks such as ambulation and navigation were significantly high in all the categories of glaucoma.

Contrast sensitivity

Glare, photophobia, poor contrast sensitivity, and light adaption are problematic for patients with advancing glaucoma. The value of assessing contrast sensitivity in a glaucoma screening may lie, first, in the positive correlation with both a large cup: Disc ratio and independently visual field loss. Second, in longitudinal studies of glaucoma suspects, progressive worsening of contrast sensitivity may possibly be a precursor of overt glaucomatous damage.[14]

The level of contrast sensitivity showed a decline as the stage of glaucoma advances, in our study, similar to studies by Richman et al. and Lorenzana et al.[15] Changes in contrast sensitivity, on the other hand, occur early and provide highly valuable insight into how well patients with glaucoma are able to function. In our study, a simple, quick method of assessing contrast sensitivity was used by asking patients to read letters of decreasing contrast in Pelli–Robson chart. In this study, contrast sensitivity was measured binocularly to simulate real life. It is seen that even in early stages, contrast sensitivity is low as compared to normal population similar to studies by Korth et al.[16]

Stereopsis

Gross stereopsis is another component of vision that is affected by glaucoma. In our study, there is a rapid decrease in the stereopsis with glaucoma progression similar to a study by Lakshmanan and George et al.[17] Decreased stereoacuity was associated with greater glaucomatous visual field loss, although it was normal with early visual field defects. Relatively moderate defects can be associated with decreased stereoacuity, and it is more pronounced in the severe stages of the disease when there is a threat to fixation.


  Conclusion Top


  1. ADREV (objective) scores correlate significantly with VFQ (subjective) scores in all the three categories of glaucoma
  2. ADREV (objective test) scores correlate better with the severity and stages of glaucoma and degree of impairment patients experience than VFQ-25 (subjective test)
  3. With respect to QoL, patients with glaucoma faced difficulty in performing fine tasks
  4. However, even advanced glaucoma cases were able to carry out their daily activities without much help
  5. Stereopsis and contrast sensitivity were the most affected with advancement of disease.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shaffer RN. The centennial history of glaucoma (1896-1996). American Academy of Ophthalmology. Ophthalmology 1996;103:S40-50.  Back to cited text no. 1
    
2.
Nassiri N, Mehravaran S, Nouri-Mahdavi K, Coleman AL. National eye institute visual function questionnaire: Usefulness in glaucoma. Optom Vis Sci 2013;90:745-53.  Back to cited text no. 2
    
3.
Mangione CM, Lee PP, Gutierrez PR, Spritzer K, Berry S, Hays RD, et al. Development of the 25-item national eye institute visual function questionnaire. Arch Ophthalmol 2001;119:1050-8.  Back to cited text no. 3
    
4.
Warrian KJ, Lorenzana LL, Lankaranian D, Dugar J, Wizov SS, Spaeth GL. Assessing age-related macular degeneration with the ADREV performance-based measure. Retina 2009;29:80-90.  Back to cited text no. 4
    
5.
Spaeth GL, Henderer J, Liu C, Kesen M, Altangerel U, Bayer A, et al. The disc damage likelihood scale: Reproducibility of a new method of estimating the amount of optic nerve damage caused by glaucoma. Trans Am Ophthalmol Soc 2002;100:181-5.  Back to cited text no. 5
    
6.
Hodapp E, Anderson DR, Parrish RK. Clinical Decisions in Glaucoma. Mosby, St: Louis, Mo; 1993.  Back to cited text no. 6
    
7.
Kapetanakis VV, Chan MP, Foster PJ, Cook DG, Owen CG, Rudnicka AR. Global variations and time trends in the prevalence of primary open angle glaucoma (POAG): A systematic review and meta-analysis. Br J Ophthalmol 2016;100:86-93.  Back to cited text no. 7
    
8.
Vajaranant TS, Nayak S, Wilensky JT, Joslin CE. Gender and glaucoma: What we know and what we need to know. Curr Opin Ophthalmol 2010;21:91-9.  Back to cited text no. 8
    
9.
Lorenzana L, Lankaranian D, Dugar J, Mayer J, Palejwala N, Kulkarni K, et al. A new method of assessing ability to perform activities of daily living: Design, methods and baseline data. Ophthalmic Epidemiol 2009;16:107-14.  Back to cited text no. 9
    
10.
Richman J, Lorenzana LL, Lankaranian D, Dugar J, Mayer JR, Wizov SS, et al. Relationships in glaucoma patients between standard vision tests, quality of life, and ability to perform daily activities. Ophthalmic Epidemiol 2010;17:144-51.  Back to cited text no. 10
    
11.
Viswanathan AC, McNaught AI, Poinoosawmy D, Fontana L, Crabb DP, Fitzke FW, et al. Severity and stability of glaucoma: Patient perception compared with objective measurement. Arch Ophthalmol 1999;117:450-4.  Back to cited text no. 11
    
12.
Friedman SM, Munoz B, Rubin GS, West SK, Bandeen-Roche K, Fried LP. Characteristics of discrepancies between self-reported visual function and measured reading speed. Salisbury Eye Evaluation Project Team. Invest Ophthalmol Vis Sci 1999;40:858-64.  Back to cited text no. 12
    
13.
Lin JC, Yu JH. Assessment of quality of life among Taiwanese patients with visual impairment. J Formos Med Assoc 2012;111:572-9.  Back to cited text no. 13
    
14.
Hitchings RA, Powell DJ, Arden GB, Carter RM. Contrast sensitivity gratings in glaucoma family screening. Br J Ophthalmol 1981;65:515-7.  Back to cited text no. 14
    
15.
Richman J, Lorenzana LL, Lankaranian D, Dugar J, Mayer J, Wizov SS, et al. Importance of visual acuity and contrast sensitivity in patients with glaucoma. Arch Ophthalmol 2010;128:1576-82.  Back to cited text no. 15
    
16.
Korth MJ, Jünemann AM, Horn FK, Bergua A, Cursiefen C, Velten I, et al. Synopsis of various electrophysiological tests in early glaucoma diagnosis-temporal and spatiotemporal contrast sensitivity, light- and color-contrast pattern-reversal electroretinogram, blue-yellow VEP. Klin Monbl Augenheilkd 2000;216:360-8.  Back to cited text no. 16
    
17.
Lakshmanan Y, George RJ. Stereoacuity in mild, moderate and severe glaucoma. Ophthalmic Physiol Opt 2013;33:172-8.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

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