Optometrists should include rehabilitation in glaucoma care

ATLANTA – Though there exists a plethora of research regarding the quality of life in glaucoma patients, there is little about rehabilitation, a speaker said here at SECO.

"The goal of all health care is to increase the quality of life," David S. Friedman, MD, MPH, PhD, the director of the Dana Center for Preventative Ophthalmology, said in his presentation. "The goal of glaucoma treatment is to maintain the quality of life of patients by preserving vision."

Friedman said that there are many issues with quality of life measures. Correlation between what patients say and their key visual field-related functions is poor. A patient's general mood and their feelings about being a burden to others was a better measure.

"Perfect correlation with measured vision loss and self-report is not expected," he said. "The strongest correlation with tests of visual function are found with glaucoma-specific questionnaires."

In assessing glaucoma and function, Friedman utilized the Salisbury Eye Evaluation, National Health & Nutrition Examination Survey and Study of Wilmer Clinic patients to study loss of function via reading, mobility, self-care tasks and social interaction.

"Older patients spend a lot of time reading and want to read – it's one of the most common complaints," Friedman said. "Reading is the most common reason for referral."

They developed a test in which participants silently read seven pages of a book; each page had the same number of words, he explained. Participants with glaucoma read 32 fewer words per minute, which Friedman said was like having more than 4 years less education.

In terms of vision loss and mobility, he explained that there were multiple aspects – getting around, getting around safely and confidence.

"Independence relies on driving," Friedman said. "If you can't drive, you're much more likely to be depressed and to be in long-term care. It's the primary mode of transportation and it's a highly valued function in the visually impaired."

Friedman said that vision loss leads to less driving and less physical activity.

"Glaucoma severity is associated with driving cessation," he said. "The findings were confirmed in second cohort of glaucoma patients. I wanted to get a sense of how much visual loss would impact loss, and 5 dB of visual field loss greatly increased quitting driving."

Friedman said that patients with greater visual field loss were also much less likely to drive at night and less likely to leave their region.

Additionally, he explained that less activity is associated with heart disease, diabetes, osteoporosis, mortality and lower quality of life.

To study physical activity, Friedman explained that they constructed an obstacle course that mimicked real life.

"Patients with bilateral glaucoma completed the course 2.4 meters per minute more slowly and with 1.65 times more bumps," he said. "There was no significant association with mobility and unilateral glaucoma. If you only have glaucoma in one eye, you're going to be OK. Keep an eye on the fellow eye."

Another study utilizing accelerometers found that those with bilateral visual field loss did only about 10 minutes of moderate/vigorous physical activity compared to 20 minutes for those with no vision loss, Friedman said.

"The impact of visual field loss on physical activity is also large," he said. "It's almost the same impact as congestive heart failure, and it's worse than arthritis."

Friedman continued, stating that vision loss also increases the risk of falls.

"Falls are the number one cause of injury-related death over age 65," he said. "Fear of falling is much more common in those with glaucoma. They walk more slowly, restrict activities, become more dependent and experience difficulties with travel, grocery shopping and preparing meals."

In his conclusion, Friedman urged doctors to focus on including rehabilitation in glaucoma care.

He explained that vision loss affects function in many ways, and while vision will not return, function can.

He also stated that rehabilitation will not happen now, but the care paradigm needs to change. To make that change, care providers can work to validate rehabilitation impact, assess barriers to low vision referral and investigate systems to administer the rehabilitation.

"People don't need to be told about ganglion cells – it's a small part," he said. "We need to be doing much more to understand what is happening to patients in their daily lives." – by Chelsea Frajerman

Disclosures: Friedman has received honoraria and travel costs for consulting to Alcon and speaking at meetings sponsored by Alcon; some research was also funded by Alcon. Friedman has also been a paid consultant to Pfizer; some data he presented resulted from research conducted in collaboration with Pfizer.