what does it look like to have glaucoma
Am J Med Sci. 2014 Nov; 348(v): 403–409.
What Practice Patients With Glaucoma See? Visual Symptoms Reported past Patients With Glaucoma
Cindy X. Hu, MD, Camila Zangalli, Doctor, Michael Hsieh, Lalita Gupta, Alice 50. Williams, Md, Jesse Richman, MD, and George Fifty. Spaeth, MD 
Received 2014 Feb 21; Accustomed 2014 Apr eleven.
Abstract:
Background:
Vision loss from glaucoma has traditionally been described as loss of "peripheral vision." In this prospective written report, we aimed to amend our clinical understanding of the visual symptoms caused by glaucoma by asking patients specific detailed questions virtually how they see.
Methods:
Patients who were clinically diagnosed with various types and stages of glaucoma were included. All had a comprehensive ocular exam, including Octopus visual field testing. Patients were excluded if they had other ocular conditions that affected their vision, including cornea, lens or retina pathologies. Patients responded to an oral questionnaire about their visual symptoms. We investigated the visual symptoms described by patients with glaucoma and correlated the severity of visual field loss with visual symptoms reported.
Results:
Ninety-nine patients completed the questionnaire. Most patients (76%) were diagnosed with primary open up-angle glaucoma. The most common symptoms reported by all patients, including patients with early or moderate glaucoma, were needing more light and blurry vision. Patients with a greater amount of field loss (Octopus mean defect >+9.4 dB) were more likely to report difficulty seeing objects to one or both sides, as if looking through dingy glasses and trouble differentiating boundaries and colors.
Conclusions:
Vision loss in patients with glaucoma is not as simple equally the traditional view of loss of peripheral vision. Needing more than light and blurry vision were the most common symptoms reported by patients with glaucoma.
Key Indexing Terms: Glaucoma, Visual symptoms, Peripheral vision, Visual field, Dissimilarity sensitivity
Glaucoma is i of the leading causes of blindness worldwide with a prevalence of over two million in those aged 40 years and older in the United states.1–3 Every bit the U.S. population continues to historic period, the prevalence of glaucoma is projected to accomplish iii million past the year 2020.3
Vision loss due to glaucoma has traditionally been described as loss of "peripheral vision"; that is, loss of vision at the outer edges.iv–seven Current educational Web sites for the full general public illustrate the loss of vision in glaucoma as "tunnel vision" or as if one is "looking through a straw" (Figure 1).eight Nonetheless, glaucomatous vision loss may involve not only narrowing of the visual field (VF) simply also deterioration in the quality of vision.9–13 Several studies have demonstrated that in improver to VF losses, deterioration of dissimilarity sensitivity and colour discrimination can occur early in the disease process.x–12 Additionally, patients may report other visual symptoms due to glaucoma, such as blurriness, dimness or cloudiness.
(A) Patient view with normal vision. (B) Patient view with glaucoma.eight Loss of vision in glaucoma has been traditionally described as "tunnel vision" or as if "looking through a straw" (courtesy: National Heart Constitute and National Institutes of Health).
Loss of peripheral vision for 1 center indicates diminished vision toward the edges of the VF of that eye (Figures iiA and 2B). Even so, anecdotally, most people with binocular vision consider their peripheral vision to be sight to the right and left side of their body (Effigy 2C). Patients exercise not consider nasal visual loss as "peripheral." Temporal areas of the VFs are areas most people consider peripheral vision, yet the temporal areas of the VF are lost late in the course of glaucoma.xiv,15 These linguistic discrepancies further complicate the description of peripheral visual loss in patients with glaucoma.
(A) Loss of "peripheral vision" can use an center or a person as its central reference signal. Loss of peripheral vision for the left eye means loss of vision toward the edges of the VF of that center. (B) The same is truthful for the right eye. (C) Loss of peripheral vision for the person implies loss of sight off to the person'southward sides, either the right and left side (as shown) or above and beneath. VF, visual field.
The goal of this prospective report was to assess the visual symptoms described by patients with glaucoma. Currently, in that location are no objective methods to assess what patients experience subjectively. Although quality of life measures address physical symptoms,16,17 there are no tools to consider visual symptoms in detail. Our study aimed to better our understanding of how glaucoma affects vision from the patients' point of view by asking specific detailed questions about how they come across. A secondary objective of the study was to correlate severity of VF loss with visual symptoms reported.
METHODS
Study Participants
All patients in this study were established patients at the Glaucoma Service of Wills Middle Hospital. Incoming patients returning for an office visit betwixt July 2011 and Dec 2011 were screened before their role visit to determine their eligibility for study inclusion. During this fourth dimension period, all eligible patients were approached (n = 102) and 3 patients refused to participate. Written informed consent was obtained from all report participants (n = 99). The Research Ethics Board of Wills Center Hospital approved this study following the principles of the Annunciation of Helsinki.
Inclusion criteria required patients to exist clinically diagnosed with glaucoma at a previous visit at least 1 twelvemonth before. Patients with principal open-angle glaucoma, normal-tension glaucoma, pseudoexfoliative glaucoma and pigmentary glaucoma were included in the study. A diagnosis of glaucoma was based on characteristic optic nervus harm on slit-lamp exam (divers every bit definite notch in the neuroretinal rim or absence of neuroretinal rim not due to some other known cause) with corresponding VF defects.18
Patients were excluded if they had other ocular conditions, trauma or surgeries that affected their vision, such every bit cornea, lens or retina pathologies. Patients with previous glaucoma or cataract surgeries were included. All the same, patients who had surgeries within the past year every bit well as previous cornea or retina surgeries were excluded. Other exclusion criteria included patients with extreme refractive errors such as high myopia (−half dozen.0 or college), loftier hyperopia (+half dozen.0 or college) or astigmatism, astute angle-closure glaucoma, ocular hypertension, history of stroke, neurologic pathology or bereft agreement of English language that would prevent the patient from participating in the report. Cataracts and intraocular lens opacity were graded based on clinical judgment of nuclear sclerosis severity. To reduce the effects of cataracts or intraocular lenses on vision, patients were excluded if they had > +1 nuclear sclerosis, > +1 posterior capsule opacification or multifocal intraocular lenses in either eye.
Questionnaire
A questionnaire was developed based on the virtually frequent visual symptoms mentioned past patients in previous studies on visual disability in glaucoma17,19,20 as well as the clinical experience of a glaucoma specialist (G.L.Southward.). An initial version of the questionnaire was administered to 8 patients (not included in this study). After interviewer debriefings, modifications to question diction was made for two questions to reduce confusion for patients. The final version of the questionnaire consisted of 25 "aye or no" equally well as iii open up-ended questions (Appendix).
A research technician administered the questionnaire orally to all study participants. A 2d research technician administered the same questionnaire for a 2d time, a minimum of 15 minutes later, to test for agreement. The interviewers read the questions out loud as they stand in the written form of the questionnaire. Patients were asked to report on the presence of their visual symptoms after correction for their refractive mistake and astigmatism. Patients were asked to employ their electric current glasses or contact lenses at the time the questionnaire was given. Trial lenses were available for patients if they did non take an updated refraction.
Visual Assessment
After the questionnaire was completed, all patients had a comprehensive ocular test, including slit-lamp examination and fundoscopy. VFs were tested monocularly for both eyes using Octopus 900 Static Perimetry 24-2 SITA standard (Haag-Streit, Stonemason, OH). The best-corrected visual acuity (BCVA) was measured using Snellen's chart at 20 feet.
Statistical Analysis
The study concluded at the end of December 2011, at which point, 99 patients had been interviewed. All 99 patients were stratified by the severity of glaucomatous damage into ane of five categories using the Octopus mean defect (MD) score of their ameliorate eye: −0.7 to +iv.four dB (early glaucoma), +4.5 to +nine.4 dB (moderate glaucoma), +9.five to +15.iii dB (advanced glaucoma), +fifteen.4 to +23.1 dB (severe glaucoma) and >23.2 dB (cease-stage glaucoma). This staging system was derived from a panel of glaucoma specialists who used published literature to convert the Humphrey's threshold values to Octopus values.eighteen,21,22 Nosotros looked at differences between historic period, gender and race between the v Dr. categories with analysis of variance and Pearson's χ2 tests. The association between Md category and questionnaire responses was assessed using the Cochran-Armitage tendency test. The Cochran-Armitage trend examination assesses for the presence of an association betwixt a variable with 2 categories (patient response) and a variable with multiple categories (MD categories). We used Fisher'due south verbal test to assess symptoms past MD ≤ +nine.4 and Doctor > +9.4 dB. The association between location of VF defect and visual symptoms reported was also adamant using Fisher'due south exact test. Information was analyzed using SAS Analytics Pro statistics software, version 9.2 (SAS Found, Inc, Cary, NC).
Nosotros transcribed the responses from the open up-concluded questions looking for any descriptor of visual symptoms. Words such every bit blurry, blurred and blurriness were all considered to be derived from 1 descriptor, blur. When descriptors such as foggy, blurry and hazy were used, they were considered unlike descriptors. The frequency of descriptors was tallied.
The location of all VF defects was documented by better eye and worse eye. In addition, we compared the agreement of laterality of field loss and the laterality of symptoms reported. When the person reported difficulty seeing to the left with corresponding left-sided field loss, the person was listed as "field and symptoms" agree. When the person reported difficulty seeing to the left and the VF loss was right sided, the person was listed equally "field and symptoms" disagree and vice versa. If the person did not report difficulty seeing to one or both sides and did non take lateral field defects, and then the person was listed as "field and symptoms" concur.
RESULTS
A summary of patient characteristics is displayed in Tabular array one. The average number of years diagnosed with glaucoma was 8.iv years. For each Doctor group, the average number of years diagnosed with glaucoma was 7.seven years for early on, 7.six years for moderate, 8.ix years for avant-garde, viii.5 years for severe and 17.2 years for end stage. In that location were no age or gender differences between the 5 MD groups, but race significantly varied (Table ii). Nigh patients (75%) had a BCVA of 20/xx in their better center, and 91% of patients had a BCVA of 20/thirty or better.
Tabular array 1
Characteristics of 99 questionnaire respondents
TABLE 2
Age, gender and race past MD category
When considering all patients, 92% reported at least 1 visual symptom after correction for their refractive error and astigmatism. Tabular array 3 displays the nearly common symptoms reported past all patients. For patients with early or moderate glaucoma without cataract (northward = 33), the most mutual symptoms reported were needing more than lite (58%), blurry vision (52%) and seeing glare (52%).
TABLE 3
Most common visual symptoms reported by all patients
For the 8 patients (viii%) who did non report any visual symptoms, the average MD of the improve heart was 4.5 dB (range, 0.9–7.9 dB). From the VFs of the meliorate eye, iv patients had mild generalized field low, 3 had an arcuate scotoma and 1 had a paracentral scotoma. All patients had early or moderate glaucoma past Physician category and a BCVA ≤20/forty.
Patients were asked the open-concluded question: "How is your vision different?" from either 5 or xv years ago. The almost mutual response was "blurriness" (xv%). Although we received similar comments from other patients, 1 patient expressed, "The world seems more blurry. It's but not real articulate. Things used to be crisper". Another patient described, "It'due south similar looking underwater." Other common responses to describe the change in vision were "fuzzy" (6%), "less clear" (6%), "harder to read" (v%), "hazy" (four%) and "cloudy" (2%). No patient complained of "tunnel vision" or loss of side vision. No patient provided novel information from the open up-concluded questions that were non addressed in the questionnaire.
Patients in a higher MD category were more probable to study half-dozen visual symptoms, shown in Table iv. Compared with patients with early or moderate glaucoma, those with field loss worse than MD of +nine.4 dB were significantly more probable to study these half-dozen symptoms (P ≤ 0.05).
Table 4
Association between MD category and visual symptoms reported a
Of the 198 optics in the written report, 196 were diagnosed with glaucoma. Two participants had unilateral glaucoma. Of the 196 eyes, there was agreement betwixt laterality of field loss and laterality of symptoms 68% of the time, and no agreement 20% of the time. For 24 eyes (12%), it was non possible to make up one's mind whether there was agreement between laterality of field loss and laterality of symptoms reported.
Table v provides a detailed account of the location of VF defects by better eye and worse eye. There was no pregnant clan betwixt location of VF and symptoms reported for the 3 well-nigh common symptoms (P = 0.89).
TABLE 5
Areas of VF defects by better centre and worse center
Patients were administered the same questionnaire twice, a minimum of 15 minutes apart. The average percent agreement was 0.89 (range, 0.73–1) between the 2 responses, and the average Kappa for agreement was 0.60.
DISCUSSION
The purpose of this study was to decide how glaucoma affects vision from patients' point of view. We administered a questionnaire to patients with glaucoma to determine visual symptoms reported, and nosotros correlated the severity of VF loss with symptoms reported.
In contrast to the traditional view of glaucoma,4–7 loss of peripheral vision was not the most common symptom reported. Needing more light and blurry vision were the most common symptoms reported, and these symptoms were not associated with any specific area of VF defect. These symptoms may be more than consistent with loss of contrast sensitivity than field loss. Decreased contrast sensitivity is an established finding in patients with glaucoma, which may be contributing to reduced image quality.eleven,23–25 The pathological thinning of the nerve fiber layer that occurs in glaucoma may explain why blurry vision was i of the most unremarkably reported symptoms.26,27
Other symptoms reported by more than 25% of patients in our study included seeing glare, letters appearing faded when reading, seeing too much light or seeing every bit if looking through dirty glasses. These reported symptoms suggest that decreased image quality, not simply VF loss or "tunnel vision," plays an important role in glaucoma. No patient in this written report reported "tunnel vision." Crabb et al28 as well found that "tunnel vision" does not accurately draw what patients with glaucoma perceive. They asked patients with primary open up-angle glaucoma to select 1 paradigm of half-dozen choices that most closely represented their perception of their VF loss, and the most oftentimes selected images were blurred patches and missing patches. No patient in their report selected the image with a singled-out black tunnel or black patches.28
Along with a decrease in the quality of vision, our report constitute that the fourth, 6th and ninth most common complaints were related to difficulties seeing to one or both sides. There was an agreement between laterality of field loss and laterality of symptoms reported approximately 65% of the fourth dimension, suggesting that field loss plays a role in difficulty seeing to the sides. Nevertheless, nigh patients in our study did non take a constricted VF. There was no understanding betwixt laterality of field loss and laterality of symptoms in twenty% of eyes, suggesting that it may not be simply the VF accounting for symptoms reported. Deterioration of prototype quality or reduced contrast sensitivity at the "periphery" may also play a role in difficulty seeing to ane or both sides, as shown in Effigy 3. This is supported by Tochel et al29 who reported that patients with glaucoma accept abnormally loftier-contrast thresholds (ie, depression-contrast sensitivity) without correlation to field loss. It was not possible to make up one's mind agreement betwixt laterality of field loss and laterality of symptoms reported for 24 eyes in our study. These patients had a nonspecific pattern of field loss or paracentral scotoma that was neither predominately right sided or left sided.
A graphic illustration of a possible progression of visual loss in a patient with glaucoma. (A) Normal vision, early glaucoma. (B) Early loss of contrast sensitivity. (C) Severe loss of dissimilarity sensitivity. (D) Light paracentral and arcuate scotomas. (E) Dense scotomas. (F) Advanced bilateral affliction. (M) Very advanced bilateral disease.
With increasing amounts of field loss, the likelihood of having visual symptoms increased, as would be expected. For each of the half-dozen symptoms that showed an association with higher Doc score, patients with field loss worse than MD +9.4 dB were more than likely to report symptoms. This suggests that patients tin can take significant field loss before reporting visual symptoms. A previous study speculated that patients with glaucomatous field defects may experience cortical reorganization or a filling in phenomenon.30 The defect may be concealed past the colors and patterns of the surroundings such that the encephalon composes a plausible prototype.xxx In the study by Crabb et al28, xvi% of patients selected the image with missing patches in their vision, which was designed to illustrate the filling in phenomenon. Similarly, our study found that 26% of patients reported areas darker or missing in their vision. These findings suggest that what patients really see is more than circuitous than VF lonely, and that patients with glaucoma practise not simply develop "tunnel vision."
Nigh patients in our report had proficient visual acuity, but 92% of patients reported at to the lowest degree 1 visual symptom. Patients may have poor image quality even in those with expert visual acuity.eleven All patients who did not report any visual symptoms had VF defects in their better centre, indicating the asymptomatic nature of early affliction even in the presence of objective VF defects.
Teaching people that glaucoma causes loss of peripheral vision may teach them to ignore the early signs of glaucoma. We found that the well-nigh common symptoms reported by patients with early or moderate glaucoma were needing more lite, blurry vision and seeing glare. Even mild or moderate glaucomatous vision loss is associated with meaning visual inability and reduced ability to perform visually related tasks, such as reading or driving.17,31,32 Furthermore, in that location is reduced quality of life and increased depression rates among patients with increasingly severe glaucoma.33,34 Earlier detection of illness and implementation of handling may aid preserve visual function and improve quality of life. Providing insight about visual symptoms due to glaucoma may be helpful for clinicians, patients and researchers. We therefore recommend that these symptoms be emphasized to patients at risk for glaucoma in public awareness campaigns and in educational materials.
An important limitation of this study was the inability to determine the actual cause for the visual symptoms described. Since other known causes for decreased vision were excluded, near had excellent visual acuity, and none had a visually symptomatic cataract, the presumption is that the crusade for the symptoms was glaucoma.
There are several other limitations. The nature of symptoms reported suggests that loss of contrast sensitivity plays role in glaucoma, merely we cannot direct verify loss of dissimilarity sensitivity in our patients because it was not measured. Symptoms reported may have been due to loss of contrast sensitivity, acuity or field, and their relative impacts are not clear. Nosotros did not examination for near visual acuity, which may also accept contributed to some of the symptoms reported, such every bit blurry vision.
Although we assessed visual symptoms by request how patients see, nosotros did not make up one's mind which eye was responsible for the symptoms reported. It has been shown that functional ability and quality of life is closely related to vision status in the meliorate eye,35–37 so nosotros analyzed patient responses using the ameliorate eye MD. Previous studies take found that monocular VFs overestimate vision loss compared with binocular integrated VFs.38,39 This is a limitation of our report, and our time to come studies will consider including both monocular and integrated VF assessments. Also, later stratification of our patients by MD category, race differed between the five groups, which may have confounded our results.
Despite these limitations, this is a novel study investigating visual symptoms reported by patients with glaucoma. We asked patients specific detailed questions about how they run into to gain a better understanding of vision loss acquired by glaucoma. Our report found that the most mutual symptoms reported by all patients, including those with early or moderate glaucoma, were needing more light and blurry vision. Vision loss in patients with glaucoma is non as uncomplicated as the traditional view of loss of peripheral vision or "tunnel vision."
ACKNOWLEDGMENTS
The authors specially give thanks Dr. Ben Leiby, Dr. Michael Waisbourd and Yang Dai.
APPENDIX.
Footnotes
Presented at the American Glaucoma Society 22nd Annual Meeting, March 2, 2012, New York, NY.
Supported past the Glaucoma Service Foundation to Prevent Blindness of Wills Heart Hospital, Philadelphia, PA.
The authors accept no conflicts of interest to disclose.
The Glaucoma Service Foundation had no involvement in the pattern or comport of the study.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4206382/#:~:text=We%20found%20that%20the%20most,blurry%20vision%20and%20seeing%20glare.
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