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The use of a glaucoma draining device (GDD) in patients with glaucoma was associated with poorer health-related quality of life (HRQOL) compared with surgical or medical management, a prospective cohort study found. The researchers speculated that this may be due in part because patients treated with a GDD may be self-conscious about the device when they interact with others.

The results, reported by Cheryl Khanna, MD, of the Mayo Clinic in Rochester, Minn., and colleagues in , showed that compared with trabeculectomy, the use of a GDD was associated with worse HRQOL scores of self-perception (difference, -12.3; 95% CI -20.9 to -3.7), interactions (-9.3; 95% CI -15.1 to -3.6) and general function (-9.4; 95% CI -18.9 to 0.0) as measured by subscales on the Adult Strabismus-20 questionnaire (AS-20) on adjusted analyses.

Compared with for medical treatment, the HRQOL scores for those with a GDD were similarly lower for self-perception (-14.7; 95% CI -23.9 to -5.5) and interactions (-7.4; 95% CI -13.5 to -1.3) on the same AS-20 subscales. Other factors associated with reduced HRQOL included worse diplopia, lower mean deviation (MD) on visual field testing in either eye, poorer visual acuity in either eye, and younger age.

"Use of a glaucoma drainage device was associated with reduced quality of life in this study even when accounting for visual acuity, visual field loss, diplopia, age, and sex in adjusted analyses," the investigators observed. "Our findings of reduced HRQOL in AS-20 self-perception and interactions subscales highlight negative self-perception in patients who undergo GDD implant, and ophthalmologists should be conscious of the potential contributors to poor HRQOL and openly discuss them with patients when gauging surgical options."

The findings are in contrast to those in a previous report in which investigators concluded that there did not appear to be any identifiable differences in the safety or efficacy of aqueous shunts and trabeculectomy for the treatment of glaucoma.

For the current study, 160 patients treated for glaucoma completed two HRQOL questionnaires -- the 25-item National Eye Institute Visual Function Questionnaire (VFQ-25) and the AS-20. A total of 87 patients were treated surgically and 73 were treated medically. Of those with surgical treatment, 36 had undergone GDD placement and 51 had undergone trabeculectomy.

Worse diplopia as measured on six subscales of the two HRQOL questionnaires was associated with reduced HRQOL, as was lower best-eye MD as measured on five of the six subscales. Lower worst-eye MD as reflected on four of the six subscales was also associated with a reduced HRQOL, as was lower worst-eye visual acuity seen on five of six subscales. Lower best-eye visual acuity as measured on two of the six subscales, along with younger age, were both associated with reduced HRQOL as well.

"Overall, in our study, more severe diplopia, more severe glaucoma in either eye (worse MD on visual field testing), poor visual acuity, treatment type, and younger age were associated with reduced quality of life," Khanna et al wrote.

"These findings suggest that patients with glaucoma should be assessed for diplopia before and after surgery, given the negative effect of diplopia on HRQOL, and potential psychosocial effects of glaucoma drainage devices should be discussed during preoperative counseling."

Limitations of the study, the team noted, included the fact that patients were not assessed for their personality type, depressive symptoms, or economic status, among other factors that can affect HRQOL scores.

AAO Perspective

Asked for his opinion, Andrew Iwach, MD, clinical spokesperson for the American Academy of Ophthalmology (AAO), who was not associated with the study, said that ophthalmologists generally try to delay or avoid incisional surgery when possible. "First of all, most patients can be successfully treated with topical medications or in-office laser procedures, and you don't want to have glaucoma incisional surgery unless you need it," he told 乌鸦传媒.

He said that the main reason for this -- and why the AAO recommends that everyone get their eyes screened for signs of glaucoma by the age of 40 -- is that early on, patients don't realize they are losing their vision because they are still asymptomatic. "So the idea is to design an intervention that will minimize the impact on the quality of a patient's life today, while doing enough to protect their vision for the rest of their life -- and the GDDs do that."

The other reason Iwach said that there was reason to question the findings of the study is that patients who received the GDD were more likely to have undergone multiple previous surgeries and have other ocular conditions than those in the other groups -- conditions that could affect HRQOL indices as well: "There are also different types of designs for GDDs, and more than half of the cases in this study had the larger, higher-risk GDDs."

The risks of trabeculectomy not discussed in the paper include trauma and very serious infections, where patients can suddenly lose significant vision long after the surgery has been done, he explained. "No procedure is perfect, so it's important to talk to the patient and modify and adjust your recommendations based not only on the state of the eye but also the patient's lifestyle to minimize the impact of the intervention.

"To me, the take-home message is: Timely diagnosis," Iwach emphasized. "The more we have to save, the less typically we have to do. The earlier the diagnosis, the better."