Quality of life and primary open-angle glaucoma in the ocular hypertension treatment study

Several contemporary ophthalmological researches have been shifting from a clinical-centered perspective to a more patient-centered approach. This evolution is particularly evident in the study of primary open-angle glaucoma (POAG), in which some investigations have focused on the complex interplay between objective medical parameters and subjective patient experiences. Given that glaucoma remains one of the leading causes of irreversible blindness globally, the integration of quality of life (QoL) metrics into routine clinical workflows is indispensable for improving patient care (1,2).

The Ocular Hypertension Treatment Study (OHTS) emerges as a pivotal investigation that offers a comprehensive exploration of incident glaucoma in a cohort of patients with ocular hypertension. This keystone investigation originally aimed at determining whether intraocular pressure (IOP) reduction could delay or prevent the onset of POAG in those patients (3,4). Unlike previous research that predominantly focused on IOP and structural damage, the present study delves into the impact of the disease on patients’ lived experiences by investigating their QoL scores during the 20 years of follow-up (5).

Patients with POAG end points were defined as presenting a reproducible visual field (VF) abnormality (VF POAG) or a reproducible optic disc deterioration (disc POAG) and were compared to controls, those who did not develop POAG. The patients’ QoL evaluation comprised the final Rasch-calibrated summary scores for the National Eye Institute 25-item Visual Function Questionnaire (VFQ) and the Glaucoma Quality of Life (GQL) questionnaire, used for comparison among all groups (6).

A pivotal finding of the study is the strong association between glaucoma severity and lower QoL scores. Patients with more advanced glaucoma stages, categorized as presenting bilateral VF defects, reported significantly lower scores for questionnaires, even after adjusting for vision-specific function in each eye or both eyes (7,8). The combined results of the questionnaires demonstrated various limitations in functionality, daily routine actions, heightened anxiety regarding disease progression, and diminished satisfaction with their vision-related activities. Moreover, the study highlights the psychological dimensions of glaucoma. Fear of blindness, treatment burden, and uncertainty about disease progression are recurring concerns for patients (9). QoL assessments can guide patient counseling and treatment decisions by providing timely insights into the psychological aspects and helping tailor interventions to individual needs.

Differences in results observed between unilateral VF POAG and bilateral VF POAG also pointed to a progressive association between worse VF defects and lower QoL scores (10).

Notably, the study found no significant differences in QoL scores between the control and early-stage POAG groups characterized solely by structural damage (disc POAG). While these findings suggest a limited perceived burden at this stage, further studies using more refined structural analysis, such as optical coherence tomography (OCT), are needed to explore potential subtle impacts (11).

Altogether, these findings argue for an expanded definition of treatment success in glaucoma management—one that encompasses psychological well-being and patient-reported outcomes alongside traditional clinical parameters (12).

Main strengths of this study include the longitudinal design of OHTS, the use of two validated QoL instruments with Rasch-calibrated summaries, and the long-term comparison between different POAG groups and controls (5,13).

Despite its contributions, the study is not without limitations. A primary concern is its reliance on subjective self-reported QoL measures, which are susceptible to biases influenced by personality traits, cultural contexts, or transient emotional states. Future research should complement these assessments with objective measures of functional vision, such as real-world task performance or mobility tests (14).

Furthermore, while the cohort is diverse, it may not fully represent underprivileged populations or subgroup-specific nuances, including those in low-resource settings or patients with systemic comorbidities. Expanding future studies to include these groups and modern examination strategies for detection of early glaucoma stages—such as angiography OCT, macular ganglion cell complex OCT analysis, or artificial intelligence-based diagnostic tools—would enhance the generalizability of findings and inform more equitable healthcare strategies (15).

The study Quality of Life and Primary Open-Angle Glaucoma in the Ocular Hypertension Treatment Study underscores the profound influence of glaucomatous VF defects on patients’ lives, reinforcing the integration of QoL as a fundamental outcome measure. This commentary calls upon the ophthalmology community to prioritize strategies to verify QoL significant points in both research and clinical practice. Considering the time to develop unilateral, and eventually bilateral VF loss, both ocular hypertensive patients and clinicians may discuss several management points progressively during follow-up visits.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Eye Science. The article has undergone external peer review.

Peer Review File: Available at https://aes.amegroups.com/article/view/10.21037/aes-25-8/prf

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://aes.amegroups.com/article/view/10.21037/aes-25-8/coif). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Gutierrez P, Wilson MR, Johnson C, et al. Influence of glaucomatous visual field loss on health-related quality of life. Arch Ophthalmol 1997;115:777-84. [Crossref] [PubMed]
2. Nelson P, Aspinall P, O’Brien C. Patients’ perception of visual impairment in glaucoma: a pilot study. Br J Ophthalmol 1999;83:546-52. [Crossref] [PubMed]
3. Gordon MO, Kass MA. The Ocular Hypertension Treatment Study: design and baseline description of the participants. Arch Ophthalmol 1999;117:573-83. [Crossref] [PubMed]
4. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension Treatment Study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol 2002;120:701-13; discussion 829-30. [Crossref] [PubMed]
5. Gordon MO, Gao F, Burkland J, et al. Quality of Life and Primary Open-Angle Glaucoma in the Ocular Hypertension Treatment Study. JAMA Ophthalmol 2024;142:935-42. [Crossref] [PubMed]
6. Marella M, Pesudovs K, Keeffe JE, et al. The psychometric validity of the NEI VFQ-25 for use in a low-vision population. Invest Ophthalmol Vis Sci 2010;51:2878-84. [Crossref] [PubMed]
7. 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;131:486-94. [Crossref] [PubMed]
8. 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;133:384-90. [Crossref] [PubMed]
9. Peters D, Heijl A, Brenner L, et al. Visual impairment and vision-related quality of life in the Early Manifest Glaucoma Trial after 20 years of follow-up. Acta Ophthalmol 2015;93:745-52. [Crossref] [PubMed]
10. Nelson P, Aspinall P, Papasouliotis O, et al. Quality of life in glaucoma and its relationship with visual function. J Glaucoma 2003;12:139-50. [Crossref] [PubMed]
11. Cheng HC, Guo CY, Chen MJ, et al. Patient-reported vision-related quality of life differences between superior and inferior hemifield visual field defects in primary open-angle glaucoma. JAMA Ophthalmol 2015;133:269-75. [Crossref] [PubMed]
12. Abe RY, Diniz-Filho A, Costa VP, et al. Predicting Vision-Related Disability in Glaucoma. Ophthalmology 2018;125:22-30. [Crossref] [PubMed]
13. Shakarchi AF, Mihailovic A, West SK, et al. Vision Parameters Most Important to Functionality in Glaucoma. Invest Ophthalmol Vis Sci 2019;60:4556-63. [Crossref] [PubMed]
14. Crabb DP, Viswanathan AC. Integrated visual fields: a new approach to measuring the binocular field of view and visual disability. Graefes Arch Clin Exp Ophthalmol 2005;243:210-6. [Crossref] [PubMed]
15. Daga FB, Gracitelli CPB, Diniz-Filho A, et al. Is vision-related quality of life impaired in patients with preperimetric glaucoma? Br J Ophthalmol 2019;103:955-9. [Crossref] [PubMed]