[Skip to Content]
[Skip to Content Landing]
Figure.
Box and Whiskers Plot Showing Unadjusted Health-Related Quality of Life (HRQOL) Scores by Treatment Group
Box and Whiskers Plot Showing Unadjusted Health-Related Quality of Life (HRQOL) Scores by Treatment Group

Top and bottom of box represent quartiles, and the whiskers represent extreme values. Unadjusted scores were lower for the glaucoma drainage device (GDD) group on each of the 4 Adult Strabismus–20 subscales (A) and the two 25-item National Eye Institute Visual Function Questionnaire subscales (B).

Table 1.  
Patient Demographics Based on Glaucoma Treatment
Patient Demographics Based on Glaucoma Treatment
Table 2.  
Univariate Linear Regression Analyses of Glaucoma Clinical and Patient Demographic Factors for Prediction of Health-Related Quality of Life Score (by Subscale: Represented as P Values with r2)
Univariate Linear Regression Analyses of Glaucoma Clinical and Patient Demographic Factors for Prediction of Health-Related Quality of Life Score (by Subscale: Represented as P Values with r2)
Table 3.  
Multiple Linear Regression Analyses of Glaucoma Clinical and Patient Demographic Factors for Prediction of Health-Related Quality of Life Score (by Subscale: Represented as Partial r2 Values)
Multiple Linear Regression Analyses of Glaucoma Clinical and Patient Demographic Factors for Prediction of Health-Related Quality of Life Score (by Subscale: Represented as Partial r2 Values)
Table 4.  
Comparison of Quality of Life Between GDD, Trabeculectomy, and Medical Groups After Adjusting for All Factors in Univariate Regression
Comparison of Quality of Life Between GDD, Trabeculectomy, and Medical Groups After Adjusting for All Factors in Univariate Regression
1.
Mills  RP, Janz  NK, Wren  PA, Guire  KE.  Correlation of visual field with quality-of-life measures at diagnosis in the Collaborative Initial Glaucoma Treatment Study (CIGTS).  J Glaucoma. 2001;10(3):192-198.PubMedGoogle ScholarCrossref
2.
Skalicky  S, Goldberg  I.  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.  J Glaucoma. 2008;17(7):546-551.PubMedGoogle ScholarCrossref
3.
Goldberg  I, Clement  CI, Chiang  TH,  et al.  Assessing quality of life in patients with glaucoma using the Glaucoma Quality of Life-15 (GQL-15) questionnaire.  J Glaucoma. 2009;18(1):6-12.PubMedGoogle ScholarCrossref
4.
Weisinger  HS.  Assessing the impact of glaucoma using the VF-14.  Clin Exp Ophthalmol. 2009;37(2):241.PubMedGoogle Scholar
5.
Lisboa  R, Chun  YS, Zangwill  LM,  et al.  Association between rates of binocular visual field loss and vision-related quality of life in patients with glaucoma.  JAMA Ophthalmol. 2013;131(4):486-494.PubMedGoogle ScholarCrossref
6.
Kong  XM, Zhu  WQ, Hong  JX, Sun  XH.  Is glaucoma comprehension associated with psychological disturbance and vision-related quality of life for patients with glaucoma? a cross-sectional study.  BMJ Open. 2014;4(5):e004632.PubMedGoogle ScholarCrossref
7.
Sawada  H, Yoshino  T, Fukuchi  T, Abe  H.  Assessment of the vision-specific quality of life using clustered visual field in glaucoma patients.  J Glaucoma. 2014;23(2):81-87.PubMedGoogle ScholarCrossref
8.
Chan  EW, Chiang  PP, Liao  J,  et al.  Glaucoma and associated visual acuity and field loss significantly affect glaucoma-specific psychosocial functioning.  Ophthalmology. 2015;122(3):494-501.PubMedGoogle ScholarCrossref
9.
Cheng  HC, Guo  CY, Chen  MJ, Ko  YC, Huang  N, Liu  CJ.  Patient-reported vision-related quality of life differences between superior and inferior hemifield visual field defects in primary open-angle glaucoma.  JAMA Ophthalmol. 2015;133(3):269-275.PubMedGoogle ScholarCrossref
10.
Gracitelli  CP, Abe  RY, Tatham  AJ,  et al.  Association between progressive retinal nerve fiber layer loss and longitudinal change in quality of life in glaucoma.  JAMA Ophthalmol. 2015;133(4):384-390.PubMedGoogle ScholarCrossref
11.
Medeiros  FA, Gracitelli  CP, Boer  ER, Weinreb  RN, Zangwill  LM, Rosen  PN.  Longitudinal changes in quality of life and rates of progressive visual field loss in glaucoma patients.  Ophthalmology. 2015;122(2):293-301.PubMedGoogle ScholarCrossref
12.
Abe  RY, Diniz-Filho  A, Costa  VP, Gracitelli  CP, Baig  S, Medeiros  FA.  The impact of location of progressive visual field loss on longitudinal changes in quality of life of patients with glaucoma.  Ophthalmology. 2016;123(3):552-557.PubMedGoogle ScholarCrossref
13.
Floriani  I, Quaranta  L, Rulli  E,  et al; Italian Study Group on QoL in glaucoma.  Health-related quality of life in patients with primary open-angle glaucoma: an Italian multicentre observational study.  Acta Ophthalmol. 2015;94(5):e278-e286.PubMedGoogle ScholarCrossref
14.
Jung  KI, Park  CK.  Mental health status and quality of life in undiagnosed glaucoma patients: a nationwide population-based study.  Medicine (Baltimore). 2016;95(19):e3523.PubMedGoogle ScholarCrossref
15.
Peters  D, Heijl  A, Brenner  L, Bengtsson  B.  Visual impairment and vision-related quality of life in the Early Manifest Glaucoma Trial after 20 years of follow-up.  Acta Ophthalmol. 2015;93(8):745-752.PubMedGoogle ScholarCrossref
16.
Sun  PY, Leske  DA, Holmes  JM, Khanna  CL.  Diplopia in medically and surgically treated patients with glaucoma.  Ophthalmology. 2017;124(2):257-262.PubMedGoogle ScholarCrossref
17.
Hatt  SR, Leske  DA, Kirgis  PA, Bradley  EA, Holmes  JM.  The effects of strabismus on quality of life in adults.  Am J Ophthalmol. 2007;144(5):643-647.PubMedGoogle ScholarCrossref
18.
Hatt  SR, Leske  DA, Holmes  JM.  Responsiveness of health-related quality-of-life questionnaires in adults undergoing Strabismus surgery.  Ophthalmology. 2010;117(12):2322-2328.e1.PubMedGoogle ScholarCrossref
19.
Hatt  SR, Leske  DA, Liebermann  L, Holmes  JM.  Changes in health-related quality of life 1 year following strabismus surgery.  Am J Ophthalmol. 2012;153(4):614-619.PubMedGoogle ScholarCrossref
20.
Hatt  SR, Leske  DA, Bradley  EA, Cole  SR, Holmes  JM.  Development of a quality-of-life questionnaire for adults with strabismus.  Ophthalmology. 2009;116(1):139-144.e5.PubMedGoogle ScholarCrossref
21.
Leske  DA, Hatt  SR, Liebermann  L, Holmes  JM.  Evaluation of the Adult Strabismus-20 (AS-20) questionnaire using Rasch analysis.  Invest Ophthalmol Vis Sci. 2012;53(6):2630-2639.PubMedGoogle ScholarCrossref
22.
Mangione  CM, Lee  PP, Gutierrez  PR, Spritzer  K, Berry  S, Hays  RD; National Eye Institute Visual Function Questionnaire Field Test Investigators.  Development of the 25-item National Eye Institute Visual Function Questionnaire.  Arch Ophthalmol. 2001;119(7):1050-1058.PubMedGoogle ScholarCrossref
23.
Pesudovs  K, Gothwal  VK, Wright  T, Lamoureux  EL.  Remediating serious flaws in the National Eye Institute Visual Function Questionnaire.  J Cataract Refract Surg. 2010;36(5):718-732.PubMedGoogle ScholarCrossref
24.
Holmes  JM, Liebermann  L, Hatt  SR, Smith  SJ, Leske  DA.  Quantifying diplopia with a questionnaire.  Ophthalmology. 2013;120(7):1492-1496.PubMedGoogle ScholarCrossref
25.
Leske  DA, Hatt  SR, Liebermann  L, Holmes  JM.  Lookup tables versus stacked Rasch analysis in comparing pre- and postintervention Adult Strabismus-20 data.  Transl Vis Sci Technol. 2016;5(1):11.PubMedGoogle ScholarCrossref
26.
Kotecha  A, Feuer  WJ, Barton  K, Gedde  SJ; Tube Versus Trabeculectomy Study Group.  Quality of life in the Tube Versus Trabeculectomy Study.  Am J Ophthalmol. 2017;176:228-235.PubMedGoogle ScholarCrossref
27.
Glen  FC, Crabb  DP, Garway-Heath  DF.  The direction of research into visual disability and quality of life in glaucoma.  BMC Ophthalmol. 2011;11(19):19.PubMedGoogle ScholarCrossref
28.
Hatt  SR, Leske  DA, Liebermann  L, Philbrick  KL, Holmes  JM.  Depressive symptoms associated with poor health-related quality of life in adults with strabismus.  Ophthalmology. 2014;121(10):2070-2071.PubMedGoogle ScholarCrossref
29.
Skalicky  SE, Martin  KR, Fenwick  E, Crowston  JG, Goldberg  I, McCluskey  P.  Cataract and quality of life in patients with glaucoma.  Clin Exp Ophthalmol. 2015;43(4):335-341.PubMedGoogle ScholarCrossref
30.
Skalicky  SE, Fenwick  E, Martin  KR, Crowston  J, Goldberg  I, McCluskey  P.  Impact of age-related macular degeneration in patients with glaucoma: understanding the patients’ perspective.  Clin Exp Ophthalmol. 2016;44(5):377-387.PubMedGoogle ScholarCrossref
31.
Balkrishnan  R, Bond  JB, Byerly  WG, Camacho  FT, Anderson  RT.  Medication-related predictors of health-related quality of life in glaucoma patients enrolled in a medicare health maintenance organization.  Am J Geriatr Pharmacother. 2003;1(2):75-81.PubMedGoogle ScholarCrossref
32.
Nelson  P, Aspinall  P, Papasouliotis  O, Worton  B, O’Brien  C.  Quality of life in glaucoma and its relationship with visual function.  J Glaucoma. 2003;12(2):139-150.PubMedGoogle ScholarCrossref
33.
Khadka  J, Pesudovs  K, McAlinden  C, Vogel  M, Kernt  M, Hirneiss  C.  Reengineering the glaucoma quality of life-15 questionnaire with rasch analysis.  Invest Ophthalmol Vis Sci. 2011;52(9):6971-6977.PubMedGoogle ScholarCrossref
Original Investigation
April 2018

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

Author Affiliations
  • 1Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
JAMA Ophthalmol. 2018;136(4):348-355. doi:10.1001/jamaophthalmol.2018.0012
Key Points

Question  What clinical factors are associated with reduced health-related quality of life in medically and surgically treated patients with glaucoma?

Findings  In this cohort study, reduced health-related quality of life was associated with worse diplopia, lower mean deviation on visual field testing, poor vision, and younger age. Previous glaucoma drainage device surgery was associated with poorer health-related quality of life on Adult Strabismus–20 domains compared with trabeculectomy or medical treatment.

Meaning  These findings suggest patients with glaucoma should be assessed for diplopia before and after surgery, given the negative effect of diplopia on health-related quality of life, and that potential psychosocial effects of glaucoma drainage devices should be discussed during preoperative counseling.

Abstract

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.

Introduction

Reduced health-related quality of life (HRQOL) has been reported in patients with glaucoma and has been associated with paracentral and inferior visual field loss, worse mean deviation (MD), retinal nerve fiber layer thinning on optical coherence tomography, and lower socioeconomic status.1-15 We reported in 2017 that diplopia and strabismus are common in patients with glaucoma and more frequent when treated with glaucoma drainage devices (GDD) than when treated with trabeculectomy or when medically treated.16 Associations with diplopia and strabismus may be important for HRQOL in patients with glaucoma because diplopia and strabismus can profoundly influence HRQOL.17-19 Therefore, in this study of prospectively enrolled patients with glaucoma, we evaluated factors associated with reduced HRQOL using instruments that are sensitive to diplopia and strabismus (the Adult Strabismus–20 Questionnaire [AS-20]20,21) in addition to the commonly used 25-item National Eye Institute Visual Function Questionnaire (VFQ-25).22 We assessed the 2 established unidimensional subscales of the VFQ-25 (visual functioning and socioemotional23) and the 4 unidimensional subscales of the AS-20 (self-perception, interactions, reading function, and general function21), with specific attention to previous glaucoma procedure (GDD vs trabeculectomy vs medical treatment).

Methods

Approval was obtained from the institutional review board of the Mayo Clinic, Rochester, Minnesota, and all participants gave informed written consent prior to participating. All procedures and data collection were conducted in a manner compliant with the Health Insurance Portability and Accountability Act.

Patients

We prospectively enrolled 195 consecutive patients with glaucoma as part of a previous study16 at their regularly scheduled follow-up glaucoma visits between August 2014 and April 2015. As previously described,16 surgical patients were required to have at least 1 month (range, 1-229 months) of postoperative follow-up. Patients with multiple tubes, previous cataract surgery, failed glaucoma surgery, scleral buckle, or penetrating keratoplasty were not excluded. Medically treated patients may have previously undergone selective laser trabeculoplasty, trabectome, iStent, or cataract surgery. Patients were required to understand English.

Patients prospectively completed 3 questionnaires: the VFQ-25,22 the AS-20,20,21 and the Diplopia Questionnaire (DQ).24 The VFQ-25 is a 25-item general vision-related quality of life22 instrument and contains 2 robust subscales (visual functioning and socioemotional) by Rasch analysis.23 The AS-20 is a 20-item instrument20 with 4 subscales (self-perception, interactions, reading function, and general function) designed to detect both HRQOL and general functional vision concerns.21 The DQ24 is a brief questionnaire designed to quantify the frequency of diplopia in standardized gaze positions over the previous week (scored from 0 to 100).24 All questionnaires were self-administered, without supervision, following simple verbal and written instructions. Patients were instructed to respond as if wearing habitual refractive correction.

For this study, we analyzed a subgroup of 160 patients (mean [SD] age, 69 [13] years; 100 were female (63%); 155 were white (97%); 149 were not Hispanic (93%); MD [SD], −13  [10] dB) from the original study16 who completed VFQ-25, AS-20, and DQ questionnaires, and either automated visual fields or Goldmann visual fields within 3 years of the study visit as a measure of glaucoma severity (closest to study visit selected when more than 1 measure was available). Patients with visual field loss primarily owing to other ocular comorbidities (eg, aniridia and trauma) were excluded. Of the included 160 patients, 87 were treated surgically and 73 were treated medically. Of those treated surgically, 36 had undergone GDD placement and 51 had undergone trabeculectomy. Patients who underwent both trabeculectomy and GDD were analyzed in the GDD group. In the GDD group, 24 (67%) had a 350 Baerveldt, 3 (8%) had a 250 Baerveldt, and 11 (31%) had a FP7 Ahmed GDD. Six patients (17%) in the GDD group had multiple tubes. Two patients (6%) in the GDD group had previous penetrating keratoplasty, 2 (6%) had previous Descemet stripping endothelial keratoplasty, and 1 (3%) had a previous scleral buckle. In the trabeculectomy group, only 1 (2%) had previous penetrating keratoplasty and 1 (2%) had previous Descemet stripping endothelial keratoplasty. No patients in the trabeculectomy group had a previous scleral buckle procedure.

Analysis

Severity of glaucoma was represented by visual field loss, recorded as an MD from the latest automated Humphrey visual field. In a preliminary analysis, we found a high correlation between MD and visual field index, and therefore, only MD was analyzed as a measure of glaucoma severity. If automated visual field data were not available (14 eyes of 9 patients), a matching method was used to impute an MD from the Goldmann visual fields. We created a reference set of paired Goldmann and Humphrey fields by using visual field data from 24 eyes of 14 patients in our cohort who had both Goldmann and automated visual fields, with MD ranging from −1.95 dB to −31.15 dB. We matched Goldmann visual fields in the HRQOL study to the closest Goldmann in the reference set and then used the corresponding MD from the matching Humphrey field for analysis. For 1 patient whose Goldmann field was worse than the worse field in the reference set (with no matching Goldmann), we imputed an MD of −32 dB.

The VFQ-25 responses were scored using published Rasch lookup tables,23 yielding a Rasch-calibrated logit score for the visual functioning and socioemotional subscales. The VFQ-25 overall composite scores were also calculated to facilitate comparison with other studies reporting composite scores (despite being limited by multidimensionality). The AS-20 responses were also scored using published Rasch lookup tables,21,25 yielding Rasch-calibrated scores from 0 to 100 for the self-perception, interactions, reading function, and general function subscales, where lower scores indicate worse HRQOL.

Statistical Analysis

Factors associated with lower HRQOL score were assessed using univariate linear regression analysis for each of the 2 VFQ-25 subscales, VFQ composite score, and 4 AS-20 subscales. Factors considered were age, sex, diplopia score (0 to 100), best-eye MD, worst-eye MD, treatment group (analyzed as 3 separate contrast statements: GDD vs not GDD, trabeculectomy vs not trabeculectomy, and medical vs not medical), best-eye visual acuity (logMAR), and worst-eye visual acuity (logMAR). Factors found to be associated with HRQOL score in univariate analysis at a 2-sided P value of .10 or less were then entered into a stepwise multiple linear regression model for each of the 6 subscales and VFQ composite score. Spearman rank correlations were used to identify strong correlations (defined as r ≥ 0.6) between factors entering the multivariate models. Any highly correlated factors were evaluated in separate multiple variable models where the highest associated of paired correlated factors was removed for the subsequent models to account for potential masking of an effect by another correlated factor (collinearity).

Nonadjusted analyses were performed using Kruskal-Wallis comparisons with Dwass, Steel, and Critchlow-Flinger methods for multiple comparisons and Hodges-Lehmann estimating methods for 95% confidence intervals on nonparametric data. A separate adjusted analysis was performed using generalized linear models for each of the 6 subscales (2 VFQ-25 and 4 AS-20 subscales) and VFQ composite score to determine whether treatment group (medical, trabeculectomy, and GDD) was specifically associated with reduced HRQOL. We adjusted for all of these factors regardless of whether they were statistically significant in the univariate analyses. Tukey-Kramer methods were used to account for multiple comparisons between treatment groups in this adjusted analysis.

To evaluate the relative effects on HRQOL between AS-20 and VFQ-25 subscales, a standardized measure of effect was calculated as a proportion of the pooled standard deviation, analogous to an effect size. All statistical analyses were performed using SAS software, version 9.4 (SAS Institute Inc).

Results
Patient Demographics

Patient demographics (age, sex, and race/ethnicity) were similar across the 3 groups with the exception of the median time from surgery to evaluation of diplopia and quality of life, which was longer in the trabeculectomy group (24 months; range, 1 month to 16 years) compared with the GDD group (5 months; range, 1 month to 6 years; P = .02; Table 1).

Univariate Linear Regression Analysis

Results of univariate linear regression analyses are shown in Table 2. For all AS-20 subscales, VFQ-25 subscales, and VFQ-25 composite score, the following 6 factors were found to be significant and entered into the multiple linear regression model: diplopia score (0 to 100), best-eye MD, worst-eye MD, treatment group (analyzed as 3 separate contrast statements: GDD vs not GDD, trabeculectomy vs not trabeculectomy, and medical vs not medical), best-eye visual acuity (logMAR), and worst-eye visual acuity (logMAR). In addition, age at examination was entered as a factor for the self-perception, interactions, and socioemotional subscales.

Multiple Linear Regression Analysis

Regarding correlation between included variables, the only factors found to have high correlations and also included in the multiple variable models were MD in the better and worse eye (rs = 0.6244); therefore, separate multiple regression models were created for these 2 factors (Table 3), where the highest associated of the correlated factors (best-eye MD) was removed for the subsequent models to evaluate association with worst-eye MD.

Reduced HRQOL was associated with worse diplopia (DQ score) on all 6 subscales (VFQ-25 visual functioning and socioemotional, AS-20 self-perception, interactions, reading function, and general function; partial r2 [rp2], 0.207-0.069). Reduced HRQOL was associated with lower best-eye MD on 5 of 6 subscales (rp2, 0.379-0.027), lower worst-eye MD in 4 of 6 subscales (in the alternative models, rp2, 0.242-0.046), treatment group (GDD vs trabeculectomy vs medical) on 3 of 6 subscales (rp2, 0.190-0.025), lower worst-eye visual acuity on 5 of 6 subscales (rp2, 0.063-0.025), lower best-eye visual acuity on 2 of 6 subscales (rp2, 0.032-0.017), and younger age on 2 of 6 subscales of the AS-20 (rp2, 0.021-0.014, Table 3). The VFQ-25 composite scores were associated with lower best-eye mean deviation, worse diplopia, and lower worst-eye visual acuity (rp2, 0.255-0.076, Table 3). Partial r2 values indicated the strongest associations with reduced HRQOL were treatment group (with GDD having the greatest effect), severity of diplopia represented by DQ score, and severity of glaucoma based on MD in either eye (Table 3).

Effect of Treatment Types

Regarding treatment type, unadjusted treatment group comparisons revealed that GDD was associated with worse HRQOL compared with medical treatment on all AS-20 subscales (difference on self-perception, −12.5 points on a 0-100 scale; 95% CI, −20.8 to −4.2; interactions, −5.2; 95% CI, −10.3 to 0.0; reading function, −22.3; 95% CI, −34.9 to −9.8; and general function, −19.9; 95% CI, −31.8 to −7.9) and VFQ-25 subscales (socioemotional, −1.03 logits; 95% CI, −1.81 to −0.26; visual functioning, −1.56; 95% CI, −2.27 to −0.85) as well as the VFQ-25 composite score (−13.4 points on a 0-100 scale; 95% CI, −20.4 to −6.4; Figure). When comparing GDD with trabeculectomy, lower HRQOL was found in patients treated with GDD on the self-perception (−9.5; 95% CI, −19.0 to 0.0), interactions (−5.2; 95% CI, −10.3 to 0.0), and general function (−12.3; 95% CI, −24.6 to 0.0) subscales of the AS-20 (Figure, A). Lower scores on both VFQ-25 subscales (socioemotional, −0.62; 95% CI, −1.23 to 0.00; visual functioning, −0.80, 95% CI, −1.55 to −0.06) and VFQ composite scores (−7.3; 95% CI, −14.8 to 0.2) were also found when comparing GDD with trabeculectomy, although the differences did not reach significance (Figure, B).

In adjusted analyses, GDD was associated with worse HRQOL on the self-perception (difference, −12.3; 95% CI, −20.9 to −3.7), interactions (−9.3; 95% CI, −15.1 to −3.6), and general function (−9.4; 95% CI, −18.9 to 0.0) subscales of the AS-20 compared with trabeculectomy (Table 4). Comparing GDD with medical treatment, HRQOL was lower with GDD for the self-perception (−14.7; 95% CI, −23.9 to −5.5) and interactions (−7.4; 95% CI, −13.5 to −1.3) subscales of the AS-20 (Table 4). Adjusted analysis revealed lower scores on both VFQ-25 subscales and VFQ composite scores when comparing GDD with either trabeculectomy or medical treatment, although the differences did not reach significance (Table 4).

Effect Size

The differences between GDD, trabeculectomy, and medical are presented as effect sizes (eTable in the Supplement) relative to the pooled standard deviations. The AS-20 interactions subscale showed the greatest difference for GDD vs trabeculectomy, whereas the VFQ-25 socioemotional subscale showed the least difference of the subscales for GDD vs trabeculectomy.

Discussion

Overall, in our study, more severe diplopia, more severe glaucoma in either eye (worse MD on visual field testing), poor visual acuity, treatment type, and younger age were associated with reduced quality of life. Regarding treatment type, patients with GDD had lower unadjusted HRQOL scores on all AS-20 and VFQ-25 subscales compared with medically treated patients. When comparing GDD with trabeculectomy, statistically lower unadjusted HRQOL scores were found on 3 of 4 AS-20 subscales.

Glaucoma drainage device was associated with reduced quality of life in this study even when accounting for visual acuity, visual field loss, diplopia, age, and sex in adjusted analyses. Patients appear to be self-conscious of the device because the specific AS-20 subscales of self-perception and interactions showed reduced HRQOL in patients with GDD compared with trabeculectomy or medically treated patients. It is possible that patients with a GDD feel the physical presence of the device or may have a psychological awareness of the device.

There are few studies with which to compare our data. A 2017 randomized prospective trial of GDD vs trabeculectomy (Tube vs Trabeculectomy [TVT] study26) did not find a difference in HRQOL between patients who were treated with a trabeculectomy vs a 350 Baerveldt following previous trabeculectomy and/or cataract extraction. The strength of the TVT study is that it was a randomized clinical trial, reducing the influence of known and unknown confounders. Nevertheless, the TVT HRQOL study reported composite VFQ-25 scores and 10 subscale scores, which have been found to be multidimensional and not psychometrically robust. Pesudovs et al23 reported that principal component analysis of the VFQ-25 revealed 2 major subscales, visual functioning and socioemotional, which we therefore reported in our study. Unlike the TVT HRQOL study, our analyses included data on visual acuity and visual field MD in each eye, not just the eye that had undergone surgery. The status of either or both eyes may affect HRQOL. An additional difference between our study and the TVT study is that our study prospectively included patients who had undergone multiple tubes, scleral buckling procedure, and penetrating keratoplasty. Similar to the TVT study, despite considering additional factors and despite using Rasch-scored VFQ-25 subscales, we also did not find statistically lower HRQOL scores in patients treated with GDD vs trabeculectomy, when assessing HRQOL using the VFQ-25. Nevertheless, we found lower HRQOL using specific AS-20 subscales (self-perception, interactions, and general function) in patients who had undergone GDD compared with trabeculectomy, suggesting that the AS-20 subscales were more sensitive than the VFQ-25 for detecting reduced HRQOL in patients with glaucoma.

In contrast to the TVT study, our study also compared the entire range of glaucoma treatment from medically controlled to trabeculectomy to patients with GDD, which allowed a more complete evaluation of HRQOL across the spectrum of disease. We intentionally included patients with severe glaucoma, using imputation methods to assign a value for MD in each patient, unlike some previous studies that excluded visual field data, or had minimal visual field data, on patients with severe disease.

In 2017, we reported a high prevalence of diplopia in patients with glaucoma,16 including those who have been treated with GDD, and therefore we also used an HRQOL instrument that is particularly sensitive to strabismus and diplopia. Considering relative effect sizes, the AS-20 self-perception, interactions, and general function subscales were particularly well able to detect differences between patients who had undergone GDD and patients who had undergone trabeculectomy. One interpretation of this result is that the effect of GDD on HRQOL may have a component related to diplopia and strabismus. Our use of instruments that are sensitive to strabismus and diplopia issues may have enhanced our ability to detect differences between GDD and trabeculectomy in our complex glaucoma patient population.

Our findings of reduced HRQOL in AS-20 self-perception and interactions subscales highlight negative self-perception in patients who undergo GDD implant. Ophthalmologists should be conscious of the potential contributors to poor HRQOL and openly discuss them with patients when gauging surgical options. We currently prefer to use translucent patching materials, such as cornea, which may mitigate a patient’s poor self-perception after GDD placement, but many patients in this study had opaque patching materials, which may partly explain why their self-perception, interactions, and socioemotional scores were so low.

Limitations

Our study was not without limitations. We had insufficient ethnic and racial diversity to consider those factors. We did not evaluate personality type, depressive symptoms, economic status, topical eyedrop therapy, coexistent cataract, or coexistent age-related macular degeneration, which others have reported to influence HRQOL scores.27-31 We did not collect longitudinal data on change in HRQOL, but we focused on a single point, including points as short as 1 month since surgery. We do not know whether the patients who underwent GDD surgery had poor HRQOL prior to that specific surgery and we acknowledge that, in our particular practice, GDDs tend to be used later in the surgical treatment algorithm. It is possible that longer duration of disease and/or a greater number of failed treatments influenced HRQOL. We did not use glaucoma-specific HRQOL instruments used by some research groups (eg, the Glaucoma Quality of Life–152,3,32 and the Glaucoma Activity Limitation–9),33 but we used the VFQ-25, which has been used by many other groups in glaucoma research. We did not perform a de novo Rasch analysis, but we used the established method of Rasch-based scoring with published lookup tables, and it is possible that the HRQOL factor structure in our patients may have differed from the reference populations.21,23 We used the AS-20 instrument20,21 because our study was designed to evaluate the specific effect of diplopia and strabismus on HRQOL.

Conclusions

Reduced HRQOL is common in patients with glaucoma previously treated with surgery and nonsurgical treatments. Overall, poor HRQOL in patients with glaucoma is associated with diplopia, lower MD on visual fields testing in either eye, poor visual acuity in either eye, treatment type, and younger age. Previous placement of a GDD was associated with poorer HRQOL scores on specific subscales of the AS-20 compared with trabeculectomy and medical treatment. The psychosocial effects of GDD, reflected in AS-20 self-perception, interactions, and VFQ-25 socioemotional subscales, should be considered when counseling patients with glaucoma. These findings suggest patients with glaucoma should be assessed for diplopia before and after surgery, given the negative effect of diplopia on HRQOL, and potential psychosocial effects of glaucoma drainage devices should be discussed during preoperative counseling.

Back to top
Article Information

Corresponding Author: Cheryl L. Khanna, MD, Ophthalmology E4, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (khanna.cheryl@mayo.edu).

Accepted for Publication: January 1, 2018.

Published Online: February 22, 2018. doi:10.1001/jamaophthalmol.2018.0012

Author Contributions: Dr Holmes and Mr Leske had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Khanna, Holmes.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Obtained funding: Holmes.

Administrative, technical, or material support: All authors.

Supervision: Holmes.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: Supported by National Institutes of Health grant EY024333 (Dr Holmes), Research to Prevent Blindness, New York, New York (an unrestricted grant to the Department of Ophthalmology, Mayo Clinic), and Mayo Foundation, Rochester, Minnesota.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentations: This paper was presented at the Association for Research in Vision and Ophthalmology annual meeting; May 5, 2015; Denver, Colorado; and at the American Glaucoma Society, February 28, 2015; Coronado, California.

References
1.
Mills  RP, Janz  NK, Wren  PA, Guire  KE.  Correlation of visual field with quality-of-life measures at diagnosis in the Collaborative Initial Glaucoma Treatment Study (CIGTS).  J Glaucoma. 2001;10(3):192-198.PubMedGoogle ScholarCrossref
2.
Skalicky  S, Goldberg  I.  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.  J Glaucoma. 2008;17(7):546-551.PubMedGoogle ScholarCrossref
3.
Goldberg  I, Clement  CI, Chiang  TH,  et al.  Assessing quality of life in patients with glaucoma using the Glaucoma Quality of Life-15 (GQL-15) questionnaire.  J Glaucoma. 2009;18(1):6-12.PubMedGoogle ScholarCrossref
4.
Weisinger  HS.  Assessing the impact of glaucoma using the VF-14.  Clin Exp Ophthalmol. 2009;37(2):241.PubMedGoogle Scholar
5.
Lisboa  R, Chun  YS, Zangwill  LM,  et al.  Association between rates of binocular visual field loss and vision-related quality of life in patients with glaucoma.  JAMA Ophthalmol. 2013;131(4):486-494.PubMedGoogle ScholarCrossref
6.
Kong  XM, Zhu  WQ, Hong  JX, Sun  XH.  Is glaucoma comprehension associated with psychological disturbance and vision-related quality of life for patients with glaucoma? a cross-sectional study.  BMJ Open. 2014;4(5):e004632.PubMedGoogle ScholarCrossref
7.
Sawada  H, Yoshino  T, Fukuchi  T, Abe  H.  Assessment of the vision-specific quality of life using clustered visual field in glaucoma patients.  J Glaucoma. 2014;23(2):81-87.PubMedGoogle ScholarCrossref
8.
Chan  EW, Chiang  PP, Liao  J,  et al.  Glaucoma and associated visual acuity and field loss significantly affect glaucoma-specific psychosocial functioning.  Ophthalmology. 2015;122(3):494-501.PubMedGoogle ScholarCrossref
9.
Cheng  HC, Guo  CY, Chen  MJ, Ko  YC, Huang  N, Liu  CJ.  Patient-reported vision-related quality of life differences between superior and inferior hemifield visual field defects in primary open-angle glaucoma.  JAMA Ophthalmol. 2015;133(3):269-275.PubMedGoogle ScholarCrossref
10.
Gracitelli  CP, Abe  RY, Tatham  AJ,  et al.  Association between progressive retinal nerve fiber layer loss and longitudinal change in quality of life in glaucoma.  JAMA Ophthalmol. 2015;133(4):384-390.PubMedGoogle ScholarCrossref
11.
Medeiros  FA, Gracitelli  CP, Boer  ER, Weinreb  RN, Zangwill  LM, Rosen  PN.  Longitudinal changes in quality of life and rates of progressive visual field loss in glaucoma patients.  Ophthalmology. 2015;122(2):293-301.PubMedGoogle ScholarCrossref
12.
Abe  RY, Diniz-Filho  A, Costa  VP, Gracitelli  CP, Baig  S, Medeiros  FA.  The impact of location of progressive visual field loss on longitudinal changes in quality of life of patients with glaucoma.  Ophthalmology. 2016;123(3):552-557.PubMedGoogle ScholarCrossref
13.
Floriani  I, Quaranta  L, Rulli  E,  et al; Italian Study Group on QoL in glaucoma.  Health-related quality of life in patients with primary open-angle glaucoma: an Italian multicentre observational study.  Acta Ophthalmol. 2015;94(5):e278-e286.PubMedGoogle ScholarCrossref
14.
Jung  KI, Park  CK.  Mental health status and quality of life in undiagnosed glaucoma patients: a nationwide population-based study.  Medicine (Baltimore). 2016;95(19):e3523.PubMedGoogle ScholarCrossref
15.
Peters  D, Heijl  A, Brenner  L, Bengtsson  B.  Visual impairment and vision-related quality of life in the Early Manifest Glaucoma Trial after 20 years of follow-up.  Acta Ophthalmol. 2015;93(8):745-752.PubMedGoogle ScholarCrossref
16.
Sun  PY, Leske  DA, Holmes  JM, Khanna  CL.  Diplopia in medically and surgically treated patients with glaucoma.  Ophthalmology. 2017;124(2):257-262.PubMedGoogle ScholarCrossref
17.
Hatt  SR, Leske  DA, Kirgis  PA, Bradley  EA, Holmes  JM.  The effects of strabismus on quality of life in adults.  Am J Ophthalmol. 2007;144(5):643-647.PubMedGoogle ScholarCrossref
18.
Hatt  SR, Leske  DA, Holmes  JM.  Responsiveness of health-related quality-of-life questionnaires in adults undergoing Strabismus surgery.  Ophthalmology. 2010;117(12):2322-2328.e1.PubMedGoogle ScholarCrossref
19.
Hatt  SR, Leske  DA, Liebermann  L, Holmes  JM.  Changes in health-related quality of life 1 year following strabismus surgery.  Am J Ophthalmol. 2012;153(4):614-619.PubMedGoogle ScholarCrossref
20.
Hatt  SR, Leske  DA, Bradley  EA, Cole  SR, Holmes  JM.  Development of a quality-of-life questionnaire for adults with strabismus.  Ophthalmology. 2009;116(1):139-144.e5.PubMedGoogle ScholarCrossref
21.
Leske  DA, Hatt  SR, Liebermann  L, Holmes  JM.  Evaluation of the Adult Strabismus-20 (AS-20) questionnaire using Rasch analysis.  Invest Ophthalmol Vis Sci. 2012;53(6):2630-2639.PubMedGoogle ScholarCrossref
22.
Mangione  CM, Lee  PP, Gutierrez  PR, Spritzer  K, Berry  S, Hays  RD; National Eye Institute Visual Function Questionnaire Field Test Investigators.  Development of the 25-item National Eye Institute Visual Function Questionnaire.  Arch Ophthalmol. 2001;119(7):1050-1058.PubMedGoogle ScholarCrossref
23.
Pesudovs  K, Gothwal  VK, Wright  T, Lamoureux  EL.  Remediating serious flaws in the National Eye Institute Visual Function Questionnaire.  J Cataract Refract Surg. 2010;36(5):718-732.PubMedGoogle ScholarCrossref
24.
Holmes  JM, Liebermann  L, Hatt  SR, Smith  SJ, Leske  DA.  Quantifying diplopia with a questionnaire.  Ophthalmology. 2013;120(7):1492-1496.PubMedGoogle ScholarCrossref
25.
Leske  DA, Hatt  SR, Liebermann  L, Holmes  JM.  Lookup tables versus stacked Rasch analysis in comparing pre- and postintervention Adult Strabismus-20 data.  Transl Vis Sci Technol. 2016;5(1):11.PubMedGoogle ScholarCrossref
26.
Kotecha  A, Feuer  WJ, Barton  K, Gedde  SJ; Tube Versus Trabeculectomy Study Group.  Quality of life in the Tube Versus Trabeculectomy Study.  Am J Ophthalmol. 2017;176:228-235.PubMedGoogle ScholarCrossref
27.
Glen  FC, Crabb  DP, Garway-Heath  DF.  The direction of research into visual disability and quality of life in glaucoma.  BMC Ophthalmol. 2011;11(19):19.PubMedGoogle ScholarCrossref
28.
Hatt  SR, Leske  DA, Liebermann  L, Philbrick  KL, Holmes  JM.  Depressive symptoms associated with poor health-related quality of life in adults with strabismus.  Ophthalmology. 2014;121(10):2070-2071.PubMedGoogle ScholarCrossref
29.
Skalicky  SE, Martin  KR, Fenwick  E, Crowston  JG, Goldberg  I, McCluskey  P.  Cataract and quality of life in patients with glaucoma.  Clin Exp Ophthalmol. 2015;43(4):335-341.PubMedGoogle ScholarCrossref
30.
Skalicky  SE, Fenwick  E, Martin  KR, Crowston  J, Goldberg  I, McCluskey  P.  Impact of age-related macular degeneration in patients with glaucoma: understanding the patients’ perspective.  Clin Exp Ophthalmol. 2016;44(5):377-387.PubMedGoogle ScholarCrossref
31.
Balkrishnan  R, Bond  JB, Byerly  WG, Camacho  FT, Anderson  RT.  Medication-related predictors of health-related quality of life in glaucoma patients enrolled in a medicare health maintenance organization.  Am J Geriatr Pharmacother. 2003;1(2):75-81.PubMedGoogle ScholarCrossref
32.
Nelson  P, Aspinall  P, Papasouliotis  O, Worton  B, O’Brien  C.  Quality of life in glaucoma and its relationship with visual function.  J Glaucoma. 2003;12(2):139-150.PubMedGoogle ScholarCrossref
33.
Khadka  J, Pesudovs  K, McAlinden  C, Vogel  M, Kernt  M, Hirneiss  C.  Reengineering the glaucoma quality of life-15 questionnaire with rasch analysis.  Invest Ophthalmol Vis Sci. 2011;52(9):6971-6977.PubMedGoogle ScholarCrossref
×