Patient-reported symptoms explain variance in glaucomatous visual field damage
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Patient-reported symptoms of glaucoma, including blurry vision, sensitivity to light and little peripheral vision, explain the variance in visual field damage, according to a cross-sectional study in Ophthalmology.
“Although the traditional description of vision loss due to glaucoma is a loss of peripheral vision resulting in tunnel-like vision, studies have shown that a variety of other measures such as contrast sensitivity, blurry vision and glare are also affected,” Yesha S. Shah, BBA, BSA, of Johns Hopkins Wilmer Eye Institute, and colleagues wrote. “More recent studies have also shown that patients do not describe their vision as tunnel-like, and not all report problems with peripheral vision; however, to our knowledge, quantitative research on the association between specific symptoms and disease severity is limited, especially when compared with the amount of research related to functional and structural testing.”
The researchers evaluated 170 patients, 95 with suspected glaucoma and 75 with confirmed glaucoma, who attended the Johns Hopkins Wilmer Eye Institute glaucoma clinic between June 2019 and August 2019.
Participants underwent perimetric testing to determine worse-eye visual field (VF) and OCT imaging to determine retinal nerve fiber layer (RNFL) thickness. To assess glaucoma symptoms, patients self-administered a 28-item questionnaire on symptom frequency and severity.
The most frequently reported symptoms among both patients and suspects were better vision in one eye (87% vs. 59%), blurry vision (77% vs. 58%), glare (71% vs. 56%), sensitivity to light (67% vs. 32%) and floaters (58% for both). Glaucoma suspects also commonly reported seeing halos (46%).
There were significant differences between the proportion of glaucoma patients vs. glaucoma suspects reporting better vision in one eye (P < .001), blurry vision (P = .001), glare (P = .015), light sensitivity (P < .001), cloudy vision (P = .001), little peripheral vision (P < .001) and missing patches of vision (P < .001).
Univariate analysis revealed that severity of little peripheral vision predicted 43% of variance in VF damage, severity of missing patches predicted 40%, severity of better vision in one eye predicted 36%, frequency of cloudy vision predicted 26%, and severity of vision worsening predicted 9%.
Multivariable analysis of these symptoms plus sociodemographic factors — age, sex, race and education — explained 62% of VF damage variance. Another model including worse-eye RNFL thickness and sociodemographic factors predicted 42% of variance. On their own, sociodemographic factors explained 8% of variance.
“Patients who report difficulties in this set of symptoms can be inferred to have greater VF damage, providing useful information in the clinical setting and an additional measure to judge glaucoma severity,” Shah and colleagues wrote. “Moreover, these symptoms suggest specific terms that are likely to reflect glaucoma damage, which can be used when communicating with patients.”
The authors proposed future research should examine whether understanding of patient-reported symptoms affects physician-patient communication, treatment adherence or outcomes, as well as whether symptoms explain VF damage variance across different glaucoma populations.
Perspective
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True or false: Glaucoma causes peripheral vision loss that slowly encroaches fixation with advancing disease. True, of course, but how often do glaucoma patients complain of this classic “tunnel-like” vision as their condition advances? More importantly, how do we address our patient’s myriad visual complaints and which ones are related to the progression or severity of the disease?
Interestingly, Shah and colleagues wondered the same. They set out to compare subjective visual complaints of glaucoma patients to their function and structure testing to determine any possible correlation. Their cross-sectional analysis found that these patient-reported subjective visual complaints explain a substantial amount of variance in VF damage and are likely to reflect glaucoma-related vision changes.
Based on my clinical experience and these pertinent findings, I’m no longer listening for patients to complain of the classic “tunnel like” vision. Instead, I am cueing in on their complaints of cloudy vision, missing patches of vision, and worsening or fluctuating vision. These complaints may seem more subtle in nature but could be a big clue that things are moving in the wrong direction.
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