Research has long established the link between mental health and glaucoma, but a new study suggests each can make the other worse in a vicious cycle of deterioration. Australian disease experts discuss what professionals can do to support their patients’ vision and well-being.
The connection between mental health and glaucoma is now well proven and accepted by the scientific and ophthalmic communities.
It’s backed up as well in the daily calls patients make to support organisation Glaucoma Australia, which says that about half of those callers report being occasionally or frequently anxious about the eye disease and its impact on their vision.
But recent US research has looked a little harder at this toxic relationship and now suggests that each might be driving the other, with a person’s deteriorating mental well-being also potentially impacting on their eyesight, and vice versa.
“Factors like anxiety, depression, and allostatic load – the cumulative burden of stress on one’s mind and body – are intertwined with the effects of glaucoma,” says Dr Sarah Van Tassel, director of the Glaucoma Service and Glaucoma Fellowship at Weill Cornell Medicine Ophthalmology in New York City.
She and her colleagues reviewed a number of studies, including several linking visual field (VF) defects with both the incidence of falls and the fear of falling. Among these, a three-year study of 342 patients with primary open-angle glaucoma found that inferior peripheral VF defects were significantly associated with fear of falling.
They concluded that anxiety could affect glaucoma progression through “stimulation of the autonomic nervous system, however the mechanism is not known”.
“It’s a complex web of interactions and it’s not as well understood in eye disease [as in some systemic diseases],” says Dr Van Tassel.
The study might not have been able to reach a conclusion about the mechanism driving this vicious cycle, but the researchers did conclude that “taking steps to help patients manage their mental health may help improve their quality of life”.
That is likely to be a challenge in many busy ophthalmic practices and businesses where chair time is at a premium and the focus is more on the eye rather than what goes on in the dark recesses behind it.
But as prominent Australian glaucoma sub-specialists Dr Brian Ang and Associate Professor Simon Skalicky point out, a more holistic view of what ails the patient is vital if glaucoma is to be treated and managed effectively.
And there are ways to do that which can preserve everyone’s well-being, including seeking support from organisations with a strong focus on the debilitating eye disease.
Five pillars of glaucoma care
The results of the US study are no surprise to Dr Ang.
“I couldn’t agree with this more,” says the Melbourne glaucoma specialist and Nutravision co-founder. “There has been recent research showing that people who are stressed, who are anxious all the time, their eye pressure actually increases.
“And for people with glaucoma, this elevation in eye pressure, up to an additional 4-5 mmHg, could make a big difference in terms of their overall glaucoma outcomes.”
That deteriorating mental health can also impact treatment.
“If you are feeling down and depressed about your vision, your motivation to continue with lifelong treatments, to be compliant with the instructions given by your eye specialist, would undoubtedly be affected,” he says.
“Sometimes you might feel, ‘what’s the point of me using the eye drops or having surgery if it’s still going to get worse, and I’m not going to bother’.”
Anxiety, stress and depression, and their impact on glaucoma patients, were part of Dr Ang’s presentation at the 2024 Specsavers Clinical Conference on the Gold Coast.
He told the hundreds of optometrists at the event and online that stress reduction was one of “five pillars” key to managing the debilitating eye condition, with the others being physical activity, restorative sleep, diet and nutrition, and what he termed neuroprotection.
“Mental stress can be overlooked for its impact on glaucoma,” he said at the time.
Between 45 and 60 minutes of daily meditation was shown to reduce intraocular pressure (IOP) by up to 25%. Also, deep breathing exercises: “Three times daily, 6 breaths a minute, 5 seconds in and 5 seconds out.”
Glaucoma was a devastating eye condition, but “optometrists can be the coach along their patients’ eye health journey”, he told the group.
Dr Ang tells Insight that just the idea of visiting an ophthalmologist can make many of his patients stressed and increase IOP.
“I try to get them to relax,” he says. “They can do deep breathing techniques to slow down their heart rate, which often helps to reduce the eye pressure to more normal levels.”
He talks about meditation with them, too.
As part of what he terms “proactive glaucoma care, a focus beyond just our conventional treatments”, he will talk to his patients about their stress management, sleep patterns, nutrition, and neuroprotection.
“They’re interconnected, and you can’t really talk about one thing without influencing the others.”
Nutrition is an important part of that conversation.
“If you eat well then you have the essential nutrients needed to function optimally, including for your eyes. But certain vitamins play a particularly important role in helping the brain and eyes adapt to stress.
“Take vitamin D and folate, for example. Both are critical for regulating neurotransmitters like serotonin and dopamine, which influence mood, cognitive function and stress response. Deficiencies in either of these can impact mental well-being and affect eye health at a cellular level.
“But beyond vitamins, certain botanicals also help the body build resilience to stress. For instance, saffron has been shown to improve mood, reduce cortisol levels, and even help lower eye pressure. Ginkgo biloba promotes circulation to both the brain and eyes, further supporting cognitive function, neuroprotection and visual health.
“So the role of nutrition in supporting the eye-brain connection – whether through diet or supplementation – should not be underplayed.”
Social support for the patient is also an important topic.
“If you’ve got family members or friends who are incredibly supportive, then you’re also more motivated to comply with your treatments, to go and do your daily exercises, do the meditation, improve your diet, etc.
“Mental health affects not just eye health but the rest of the body, and in ophthalmology we are very much into this sort of concept where, ‘oh, we don’t deal with the rest of the body, and much less mental health’,” he says.
“But the reality is that mental health will affect your eyes and if we truly want the best outcome for our patients, then this is something that we have to be cognisant of, and we have to appreciate that mental health plays an important role.”
Dr Ang acknowledges that taking a more holistic approach and discussing a patient’s mental health and general well-being also takes more time, which is not always plentiful at busy practices.
“When you’ve only got 15-20 minutes, the last thing you want is a lengthy chat about mental health, so just start with one or two questions – how’s your mental health been? Have you been stressed at work?
“At the next consultation you can go with how are you doing? How do you feel and do you need help? That way they can open up.”
He believes his patients respond well to that extra level of care and interest in their well-being, which builds all-important trust.
But like their patients, eyecare professionals don’t have to do this alone.
Dr Ang says there are numerous excellent groups to support the mental health of both practice and patient.
“If you want support with regards to glaucoma, then Glaucoma Australia is an excellent resource,” he says.
“In terms of specific mental health organisations, there are a few – Beyond Blue is an excellent organisation, and sometimes even talking to the counsellor, the GP or the family doctor will be quite a good option.”
Know your limitations
Looking elsewhere for support is good advice, says A/Prof Skalicky.
It is important that optometrists, ophthalmologists and others recognise their limitations.
“I’m an ophthalmologist, not a psychiatrist,” he says. “And in the odd case where I really feel like mental health here is a big issue, and it’s not under control, I would call the GP.
“It’s not necessarily my place to refer directly to a psychiatrist.”
Like Dr Ang, the conclusions of the recent US research are not surprising to the glaucoma and cataract sub-specialist, who is also an Associate Professor at Melbourne University.
“I published work with Professor Ivan Goldberg almost 20 years ago, and we looked at the link between glaucoma and depression, and we found very similar results – that depression seems to magnify the quality-of-life impact of glaucoma, and that glaucoma was linked with worse depression.
“But I note that having any chronic illness that is potentially degenerative, like glaucoma, is linked with depression, so much of the relationship between glaucoma and depression is not necessarily specific to glaucoma.”
That impact on mental health can start even before the deterioration of vision.
“Patients might see fine but they’re worried that they’re going to lose their vision over time, or they’re worried that they might pass this on to their children or they’re worried about the medical interventions and many visits to the doctor that might impact on their life and job,” says A/Prof Skalicky.
“There is a certain degree of psychological overlay in there, and I think that’s important for us as clinicians to recognise.
“It often startles me when I see a patient for whom I think there’s no problem here – they’ve got healthy optic nerves, the pressure is just a little bit high but not a concern for me as a clinician,” he says.
“But from where the patient is sitting, they’re incredibly anxious, incredibly upset; they’ve been waiting for this appointment and have really focused their energy on it.
“If I am not aware of that dimension and I just send them on their way, I’ve missed an opportunity to do some good, to open that dialogue.”
He believes nothing is more important for patients than keeping up with visits to their eyecare professionals and sticking to the treatment regime.
But there is also plenty of evidence to show that lifestyle plays an important role and lifestyle habits like meditation can reduce stress and IOP.
“My patients commonly ask me, what can they do in their lifestyle to help with glaucoma? As well as having this laser treatment or taking these drops and regularly seeing me, what can they do in their life to help?”
Again, that could be about promoting certain foods rich in various vitamins, such as vitamin B3, which is known to play a role in halting the progression of glaucoma, but also fresh fruit and green leafy vegetables as part of a healthy, balanced diet.
But busy professionals don’t have to have all the answers.
They can share the load with others, says A/Prof Skalicky.
“You should remember you are just one piece of the puzzle,” he says.
“There are plenty of other people involved here – the optometrist, the pharmacist, the GP, the support person, even the administrative staff at our practices, and the family to talk to.”
He believes handing out flyers linked to his website, or from organisations like Glaucoma Australia, can help them with further support.
Patients with good information about their ailment and their options feel empowered, and that supports good mental health.
“Patients want to feel empowered to look after their own illnesses, and that ultimately comes back to these concepts of a quality therapeutic relationship and putting your patients first.”
But professionals also need to be mindful of their own mental health, especially when anxious, vulnerable patients are sitting in front of them contemplating deteriorating vision.
Self-awareness is important.
“It’s about, as a clinician, just being aware of your own mindset,” he says. “If something’s annoying you and you’re not addressing it, that will come out, and in a negative way in your patient interaction.”
Clinicians should practise what they preach: “Look after yourself mentally, physically exercising, getting good sleep, eating well, having support around you, taking breaks, taking holidays, and also talking, feeling free to talk to colleagues about when cases don’t go so well.”
A problem shared can be a problem halved.
“We don’t need to solve everything on our own.”
That’s where Glaucoma Australia comes in. It provides free support to not only the patients but also their family and carers.
“Many patients have questions that are not able to be addressed ‘on the spot’ due to being overwhelmed or not completely understanding the information that has been relayed,” it says.
“Initial contact can be made via our national free-call number, web chat, or Oculo referral.
“Also, our website provides detailed information on glaucoma through online resources, such as articles, videos, live webinars and downloadable guides covering topics from diagnosis and treatment options to lifestyle tips.”
People can access one-on-one tailored support through the organisation’s SiGHTWiSE patient support program, which provides access to Orthoptist Patient Educators.
“Our team is also aware of external third-party resources, such as agencies for low vision aids and financial assistance.”
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