Glaucoma and associated visual acuity and field loss significantly affect glaucoma-specific psychosocial functioning.

OBJECTIVE: To examine the impact of glaucoma and visual acuity (VA) and visual field (VF) losses on psychosocial functioning (PF). DESIGN: Cross-sectional study. PARTICIPANTS: We compared PF between 192 participants with bilateral glaucoma with VA or VF losses and 40 controls from a tertiary eye hospital clinic in Singapore. METHODS: Glaucoma was defined using the Hodapp-Anderson-Parish criteria. Four psychosocial outcomes of the Glaucoma Quality of Life 36 questionnaire were psychometrically assessed using Rasch analysis. Multivariate regression was performed to determine the independent impact of glaucoma and VA and VF losses on PF. The impact of VA and VF on PF were evaluated by restricted cubic spline analysis. MAIN OUTCOME MEASURES: Anxiety, self-image, psychological well-being, and confidence in health care. RESULTS: The mean age of participants was 66.2±11.0 years, and 63% were male. In the better eye, VA and mean deviation were Snellen 20/25 and -8.89±6.52 dB, respectively. In multivariate models, glaucoma patients had 63.0% greater anxiety (95% confidence interval [CI], -66.0% to -61.2%; P<0.001), 71.0% lower self-image (95% CI, -74.1% to -68.5%; P<0.001), 38.3% less psychological well-being (95% CI, -37.4% to -39.0%; P<0.001), and 32.4% reduced confidence in health care than patients without glaucoma. The worst VA and VF categories had the most reduced PF (range, 26.0% to 81.5%; P<0.001 for all associations) compared with controls. With worsening VA, there was a linear increase in anxiety (P=0.009) and decrease in self-image (P=0.005). With worsening VF from 0 to -12.1 dB (P=0.003), anxiety increased before plateauing. Self-image decreased as VF worsened from 0 to -10 dB (P<0.001), and confidence in health care decreased when VF worsened from 0 to -9.3 dB (P=0.008). However, self-image and confidence in health care actually improved at greater levels of VF loss beyond these thresholds. CONCLUSION: Glaucoma negatively affects PF. Early stage glaucoma with mild VF loss adversely affects anxiety, self-image, and confidence in health care. As VA worsens in advanced glaucoma, anxiety further increases and self-image deteriorates. Ophthalmologists and glaucoma patients need to be aware that both VA and VF losses at different stages of glaucoma negatively impact PF.

Marital status and its relationship with the risk and pattern of visual impairment in a multi-ethnic Asian population.

BACKGROUND: To examine whether marital status is a significant determinant of visual impairment (VI) in urban multi-ethnic Asian population. METHODS: We conducted a population-based study of Singapore-resident ethnic Malays, Indians and Chinese aged ≥40 years. Ophthalmic examination included the assessment of presenting and best-corrected visual acuity (PVA and BCVA) using standardized procedures. Information regarding marital status and socioeconomic status were obtained from an interviewer-administered questionnaire. RESULTS: Among the 10 033 participants, 7756 (77.3%) were married; 589 (5.9%) were single; 407 (4.1%) were separated and 1265 (12.6%) were widowed. Being single (never married) or widowed were significantly associated with best-corrected VI (BCVA < 20/40) and presenting VI (PVA < 20/40) (odds ratios: 1.37-1.59) compared with married people even after adjustment for age, sex and socioeconomic status. A marginal prediction model showed that the negative effect of unmarried status on VI increased with age and was stronger among Malays and Indians, but the influence did not vary with gender, educational level and diabetic status. CONCLUSIONS: Unmarried status is associated with VI, particularly among elderly Malays and Indians. Our findings suggest that single and widowed adults may benefit from specific social support and eye care programmes.

Cardio-metabolic risk factors and prehypertension in persons without diabetes, hypertension, and cardiovascular disease.

BACKGROUND: Prehypertension has been shown to be an early risk factor of cardiovascular disease (CVD). We investigated the prevalence and pattern of cardiometabolic risk factors in prehypertension in three ethnic Asian populations in Singapore. METHODS: We examined data from Chinese (n=1177), Malay (n=774), and Indian (n=985) adults aged 40-80 years who participated in three independent population based studies conducted from 2004-2011 in Singapore who were free of diabetes, hypertension and previous CVD. Prehypertension was defined as systolic blood pressure (BP) 120-139 mm Hg or diastolic BP 80-89 mm Hg. Random blood glucose, glycated haemoglobin (HbA1c), body mass index (BMI), triglycerides, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol were examined as indicators of adverse cardiometabolic profile. The association between metabolic variables and prehypertension was examined using logistic regression models adjusting for potential confounders. RESULTS: The prevalence of prehypertension was 59.8% (Chinese), 68.9% (Malays) and 57.7% Indians. Higher levels of blood glucose, HbA1c and BMI were significantly associated with prehypertension in all three ethnic groups, odds ratio (95% confidence interval) of prehypertension in Chinese, Malays and Indians were: 1.42 (1.10, 1.83), 1.53 (1.05, 2.24), 1.49 (1.13, 1.98) for high-glucose; 3.50 (1.01, 12.18), 3.72 (1.29, 10.75), 2.79 (1.31, 5.94) for high-HbA1c; 1.86 (1.34, 2.56), 2.96 (2.10, 4.18), 1.68 (1.28, 2.20) for high-BMI. In addition, higher levels of LDL cholesterol in Chinese and higher levels of triglycerides were significantly associated with prehypertension. These associations persisted when metabolic variables were analysed as continuous variables. CONCLUSIONS: Higher levels of blood glucose, HbA1c and BMI were associated with prehypertension in all three ethnic groups in Singapore. Screening for prehypertension and lifestyle modifications could potentially reduce the burden of CVD in otherwise healthy Asian adults living in Singapore.

How much eye care services do Asian populations need? Projection from the Singapore Epidemiology of Eye Disease (SEED) study.

PURPOSE: We quantified and measured the needs for specific eye care services, including refractive services (RS), annual eye examination services (AES), cataract surgery services (CSS), and low vision services (LVS) in urban adult populations in Asia. METHODS: We conducted three population-based studies of Singapore-resident Chinese, Malays, and Indians aged ≥40 years to measure the proportion of people who needed specific eye care services. RESULTS: Our data included 3353 Chinese, 3280 Malays, and 3400 Indians (participation rate 73.6%). Overall, approximately 70% of the populations needed eye care services and more than 30% had more than one need. The age-standardized proportion of people who need RS, AES, CSS, and LVS were 65.3%, 22.4%, 12.5%, and 0.5%, respectively, in Chinese. These figures were 49.6%, 33.6%, 11.0%, and 0.7%, respectively, in Malays, and 55.6%, 40.0%, 13.4%, and 0.8%, respectively, in Indians. With demographic change, our projection showed that the number of adults needing eye care services in urban Asia will grow from 437 million in 2010 to 827 million in 2030. Diabetes was a major cause of AES and a significant predictor for CSS, whereas higher blood pressure was a predictor for AES. CONCLUSIONS: The needs for eye care services in an urban setting in Asia is high, particularly the needs for RS, AES, and CSS. The high prevalences of diabetes and hypertension are the driving factors underlying these needs. The burden of providing such eye care services highlights the need for new strategies for improvements in primary care and capacity building for eye care professionals other than ophthalmologists.

Impact of glaucoma severity and laterality on vision-specific functioning: the Singapore Malay eye study.

PURPOSE: We determined the impact of glaucoma severity and laterality on vision-specific functioning (VF) in an Asian population. METHODS: The Singapore Malay Eye Study (SiMES) was a population-based cross-sectional study of 3280 Malays aged 40 to 80 years. VF was assessed using the VF-11 questionnaire. Associations between VF-11 score and glaucoma clinical indices (glaucoma severity in better and worse eyes, and laterality) were determined by multivariate regression modeling. Glaucoma severity was defined as mild, moderate, advanced, and severe based on the Hodapp-Anderson-Parish system. Rasch analysis was used to validate the VF-11 and determine its psychometric properties. RESULTS: Of 926 persons analyzed, 123 had glaucoma (13.3% glaucoma prevalence in analyzed sample). The mean ± SD VF score was 3.64 ± 1.05 log of odds units (Logits). In multivariate models adjusting for sociodemographic, ocular, and systemic variables, poorer VF was associated with increasingly worse eye visual field loss (ß = 0.016, 95% confidence interval [CI] 0.004-0.029, P < 0.001), but not that of the better eye (P > 0.05). Compared to controls, VF was reduced in individuals with worse eye advanced and severe glaucoma (ß = -0.65, 95% CI -1.03 to -0.28, P < 0.05), but not mild or moderate glaucoma (P > 0.05). Compared to controls, VF was reduced in unilateral (ß = -0.29, 95% CI -0.54 to -0.04, P < 0.05), but not bilateral glaucoma (P > 0.05). These associations remained significant after adjusting for presenting and best-corrected visual acuity. CONCLUSIONS: Among Singaporean Malays, unilateral, and advanced and severe glaucoma in the worse eye significantly impacts on VF. Identifying early-stage glaucoma, preventing progression, and visual rehabilitation in advanced glaucoma are important aspects of glaucoma management.

Vision impairment and major causes of vision loss impacts on vision-specific functioning independent of socioeconomic factors.

PURPOSE: To quantify the eye disease-specific impact of unilateral and bilateral vision impairment (VI) on vision-specific functioning (VF). DESIGN: The Singapore Indian Eye population-based study. PARTICIPANTS: Ethnic Indians older than 40 years of age living in Singapore. METHODS: Participants underwent standardized ophthalmic assessments for VI and blindness, defined using presenting visual acuity (United States definition). Sociodemographic data were recorded using a standardized questionnaire. Rasch analysis was used to validate the Visual Function Index 11 and to determine its psychometric properties. The major causes of VI (i.e., cataract, refractive error, age-related macular degeneration, diabetic retinopathy [DR], and glaucoma) were determined by ophthalmologists on examination. Multivariate linear regression analysis was performed to assess the impact of VI on the overall VF Rasch score. MAIN OUTCOME MEASURES: Vision-specific functioning. RESULTS: Three thousand three hundred ninety-six persons were analyzed. Participants with VI had a systematic reduction in VF score compared with those with normal vision in both eyes, ranging from -11.2% normal vision in one eye and low vision in the other eye (95% confidence interval [CI], -12.2% to -10.3%; P<0.001), to -12.7% blindness in one eye and normal vision in the other eye (CI, -15.1% to -10.4%; P<0.001), to -19.4% low vision in both eyes (CI, -20.8% to -18.1%; P<0.001), to -52.9% blindness in one eye and low vision in other eye (CI, -55.3% to -50.4%; P<0.001), to -77.2% blindness in both eyes (CI, -82.4% to 72.0%; P<0.001). The impact of VI on VF score varied across different major causes of vision loss, regardless of socioeconomic factors. Vision impairment attributed to cataract in one or both eyes had a significant decrease in VF score by 17.7% and 22.3%, respectively, compared with those with normal vision in both eyes (P<0.001). The impact of unilateral and bilateral VI on VF score was greater in participants with glaucoma (32.2% in unilateral cases and 35.9% in bilateral cases; P<0.001) and DR (29.4% in unilateral cases and 33.3% in bilateral cases; P<0.001). CONCLUSIONS: Vision impairment and major age-related eye diseases such as cataract, DR, and glaucoma are associated significantly with worse deterioration in VF, regardless of education level, literacy adequacy, or immigration pattern. Glaucoma and DR seemed to have a greater negative impact on VF score compared with cataract. This study highlights the importance of disease-specific interventions in reducing the adverse impact of VI on daily activities.

Acceptance, attitudes, and beliefs of Singaporean Chinese toward an ocular implant for glaucoma drug delivery.

PURPOSE: We investigated patients' attitudes and perceptions toward a subconjunctival implant as a novel ocular drug delivery method for glaucoma. METHODS: We recruited 344 Chinese patients with primary open angle or angle closure glaucoma currently on topical antiglaucoma medication for a minimum of six months from specialist glaucoma clinics. Sociodemographic data, and information about patients' general and ocular health were collected. Beliefs about medicines, glaucoma, eye drops, and self-reported adherence were assessed by trained interviewers using validated questionnaires. A description about the implant was provided and patients subsequently were assessed on their understanding and acceptance. RESULTS: Of the 344 Chinese patients enrolled, 216 (62.8%) would accept the implant as a replacement for their current eye drops. Of those who accepted the implant, 99 (45.8%) were willing to accept it at similar costs, while 40 (18.5%) and 20 (9.3%) patients were willing to pay 1.5 and 2 times the cost of their present medication, respectively. Patients who accepted the implant had more severe glaucoma (P = 0.015) and felt that the implant was more helpful than eye drops (P < 0.001). Beliefs toward medicines, glaucoma, eye drops, self-reported adherence, and sociodemographic factors did not have a significant impact on the patients' decisions. CONCLUSIONS: An ocular drug implant would be an acceptable alternative to topical eye drops for subgroups of glaucoma patients.

Assessing disutility associated with diabetic retinopathy, diabetic macular oedema and associated visual impairment using the Vision and Quality of Life Index.

BACKGROUND: Use of generic multi-attribute utility instruments (MAUI) to assess the impact of diabetic retinopathy (DR) on health-related quality of life (HRQoL) has produced inconsistent findings. Therefore, we assessed the impact of DR, diabetic macular oedema (DME) and associated visual impairment on vision-related QoL (VRQoL) using a vision-specific MAUI. METHODS: In this cross-sectional study, 203 diabetic patients were recruited from specialised eye clinics in a Melbourne tertiary eye hospital. Severity of combined DR/DME was categorised as: no DR/no DME, mild non-proliferative DR (NPDR) and/or mild DME; moderate NPDR and/or moderate DME and vision-threatening DR (severe NPDR or proliferative DR (PDR) and/or severe DME) in the worse eye. Visual impairment was categorised as: none (up to 0.18 logMAR); mild (from 0.18 to 0.3 logMAR); moderate (from 0.3 to 0.48 logMAR); severe (from 0.48 to 0.78 logMAR); and profound (worse than 0.78 logMAR). The Vision and Quality of Life Index (VisQoL) vision-specific MAUI was the main outcome measure. As the distribution of the utilities was skewed, independent associations with covariates were explored using multivariable quantile regression models (five groups: 15(th) , 30(th) , 45(th) , 60(th) and 75(th) percentiles) ranging from poorest to highest VRQoL. RESULTS: Participants' median age was 65 years (range: 27 to 90 years). Of the 203 participants, 50 (24.6 per cent) had no DR/DME, 24 (11.8 per cent) had mild NPDR/DME, 47 (23.2 per cent) had moderate NPDR/DME and 82 (40.4 per cent) had vision-threatening DR. After adjusting for relevant covariables, only profound visual impairment was independently associated with VisQoL utilities (ß= -0.297 ± 0.098 p < 0.01). Severity of DR/DME was not significantly associated with any group of VisQoL utilities. CONCLUSION: The variation in VisQoL utilities was attributed to profound visual impairment but not mild, moderate or severe visual impairment or DR/DME severity. These findings support the use of vision-specific MAUI to capture the impact of profound visual impairment associated with DR and DME. A DR-specific MAUI might be required to assess the specific utility deficits associated with DR/DME across the spectrum of the condition.

Racial differences in the prevalence of diabetes but not diabetic retinopathy in a multi-ethnic Asian population.

PURPOSE: To compare the prevalence and risk factors of diabetes (DM) and diabetic retinopathy (DR) in a multi-ethnic Asian population of Chinese, Malays, and Indians in Singapore. METHODS: A total of 2919 individuals participated in a population-based, cross-sectional study in Singapore of Chinese (n = 1633), Malays (n = 658), and Indians (n = 628) aged 40 to 95 years, with retinal photographs, graded using the Early Treatment Diabetic Retinopathy Study (ETDRS) severity scale. DM was defined as fasting plasma glucose ≥ 7 mmol/L, self-reported physician-diagnosed diabetes, and use of glucose-lowering medication. RESULTS: The overall age-standardized prevalence of diabetes was 13.8% (Chinese, 11.5%; Malays, 17.1%; and Indians, 21.6%; P < 0.0001). Among persons with diabetes (n = 401), the overall age-standardized prevalence of DR was 25.4% (20.1%, 24.8%, and 28.9% in Chinese, Malays, and Indians, respectively; P = 0.290). In multivariate analysis, longer diabetes duration (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.09, per year increase), higher glycated hemoglobin (OR 1.25; 95% CI, 1.01-1.54, per 1% increase), and serum creatinine levels (OR, 1.01; 95% CI, 1.00-1.03, per mg/dL increase) were the independent risk factors of DR in the whole population. Race was not found to be associated with DR (OR, 1.35; CI, 1.00-1.83). The associations of major risk factors with DR were similar among the three ethnic groups. CONCLUSIONS: There was a significant difference in the prevalence of diabetes between Chinese, Malays, and Indians. The main risk factors of DR, similar among the three ethnic groups, are longer diabetes duration, higher hbA1c, and higher creatinine levels. No significant racial differences were found in the prevalence of DR among persons with diabetes.