Module 9: Eye Disease and Mental Health

Given the physical and social harms of blindness and eye disease, there is a well-established link between poor eye health and mental health, and it is important that those involved with eye care be aware of this.(1)(2)(3) Below are some of the primary effects of eye disease on mental health.

Depression

Vision loss remains a substantial predictor of depression, even after age, gender, financial strain, and social support are controlled for.(4)  In addition, patients with poor visual acuity are more likely to be depressed while waiting for cataract surgery. (5),(6),(7)  This is important because the wait to receive cataract surgery can take months in many developed countries, and even longer in the developing world.(8) 

One of the major causes of blindness is age-related macular degeneration (AMD), with prevalence estimates ranging from 10% among people aged 65 to 75 to 30% among those aged 75 and older.(9)  Thus, it is a large cause of disability in older people, lowers patients’ quality of life, and is a risk factor for depression. “Until recently, the emotional impact of AMD was rarely addressed, leaving patients with few options for coping. Fortunately, there has been a recent interest in the psychosocial consequences of AMD and blindness in general, and this research underscores the extent of the disability caused by eye diseases”. (10)

Anxiety

Vision loss can also increase feelings of anxiety, further preventing individuals from caring for themselves and others.(11)Eye disease increases the likelihood of social withdrawal, isolation, falls, and medication errors.  Furthermore, “progressive vision loss can be associated with a syndrome of hallucinations which, although benign, can be disturbing to patients.”(12)  Emotional reactions to vision loss can include psychological distress, and older persons with visual impairments are more likely to be institutionalized.(13)  In fact, loss of vision is one of the most feared results of aging.(14) 

Social Withdrawal

Vision impairment may also have negative psychosocial consequences that affect everyday life.  This must be taken into consideration in research and practice.  A loss of vision constitutes more than a physiological loss, as it substantially impairs day-to-day routines and leisure time.  Vision loss may lead to general impairment of mental health which renders individuals unable to work or pursue activities that were previously of interest. 

Visual impairment is likely to affect mobility and access to social contacts. Social isolation, disengagement, loneliness, and loss of social support may result. However, continued social support may be an effective buffer against the consequences of vision loss and the negative effects of stress caused by visual impairment. For example, visual acuity is directly associated with anxiety and depression, but only for subjects with limited access to family support.(15)(16)(17) In addition, results indicate that high-quality social support correlates with fewer depressive symptoms and better adaptation to vision loss.(18) It is important for family members and communities to understand eye disease and work to eliminate any associated stigma that can further worsen social isolation.

The Power of Medical Intervention

There is a misconception that vision is less important in old age and should be expected as part of the ageing process. In fact, this is not the case. Research has shown that cataract surgery has a far-reaching impact on the quality of life for the elderly. Further, “[r]estoration of vision that accompanies most cataract operations reduces both psychiatric and somatic symptoms."(19)  For example, nursing home residents who underwent cataract surgery because of functional problems experienced significant improvements in their quality of life, in addition to dramatically improved vision.(20)  In a study in Kenya and Bangladesh, those suffering from other health problems or diseases expressed that their improved vision was of tremendous value.(21)

Following cataract surgery, many individuals are able to once again engage in productive activities such as business, farming, or maintaining the household.  In addition, many experience an increased level of independence after surgery, better communication ability, and stronger social relationships:

“Now when I meet someone in the community, I can say hello and genuinely feel I have communicated and I can tell whether people are truly saying hello with a good heart. Before [surgery] I didn't want to talk to people because I didn't know whether to trust if they were being true. It's easier to talk to people now.” (22) (Kenya)

As these examples show, in the absence of medical intervention (spectacles, surgery, low vision care, or rehabilitation) and family/community support, visual impairment can have a negative impact on mental health and quality of life. These effects range from practical issues regarding daily activities to a subtle influence over psychological wellbeing.  The significant physiological and psychological benefits of surgery reveal the power of available treatment to transform lives.

Footnotes

(1) “World Blindness Overview.” Himalayan Cataract Project. www.cureblindness.org.

(2) Wagner-Lampl, A. and Oliver, G.W. “Folklore of Blindness.” Journal of Visual Impairment & Blindness. 1994; 88.3.

(3) Faal, H. and Gilbert, C. “Convincing Governments to act: VISION 2020 and the Millennium Development Goals.” Community Eye Health Journal. 2007; 20(64): 62-64.

(4) Bazargan M, Hamm-Baugh VP. The relationship between chronic illness and depression in a community of black elderly persons. J Gerontol Soc Sci. 1995;50B(2): 119-127.

(5) Hodge W, Horsley T, Albiani D, et al. The consequences of waiting for cataract surgery: a systematic review. CMAJ 2007;176:1285–90.

(6) Harwood RH, Foss AJ, Osborn F, Gregson RM, Zaman A, Masud T. Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial. Br J Ophthalmol 2005;89:53–9

(7) Laidlaw DA, Harrad RA, Hopper CD, et al. Randomised trial of effectiveness of second eye cataract surgery. Lancet 1998;352:925–9.

(8) Mojon-Azzi SM, Mojon DS. Waiting times for cataract surgery in ten European countries: an analysis using data from the SHARE survey. Br J Ophthalmol 2007;91:282–6.

(9) Casten RJ, Rovner BW, Tasman W. Age-related macular degeneration and depression: a review of recent research. Curr OpinOphthalmol 2004;15:181–3.

(10) Ibid.

(11) Augustin A, Sahel JA, Bandello F, et al. Anxiety and depression prevalence rates in age-related macular degeneration. InvestOphthalmol Vis Sci 2007;48:1498–1503.

(12) Menon GJ:  Complex visual hallucinations in the visually impaired: a structured history taking approach.  Arch Ophthalmol. 2005;(3): 349-355.

(13) Brézin AP, Lafuma A, Fagnani F, Mesbah M, Berdeaux G:  Blindness, low vision, and other handicaps as risk factors attached to institutional residence.  Br J Ophthalmol. 2004; (10): 1330-1337.

(14) Rosenberg EA, Sperazza LC:  The visually impaired patient.  Am Fam Physician. 2008; 77 (10): 1431-1436.

(15) Burmedi, D., Becker, S., Heyl, V., Wahl, H. -W., & Himmelsbach, I., (2002b). Emotional and social consequences of age-related low vision: A narrative review. Visual Impairment Research,4, 47-71.

(16) Barron et al. Marital status, social support, and loneliness in visually impaired elderly people. J Adv Nurs. 1994;19(2):272-280.

(17) Oppegard et al. Sensory loss, family support, and adjustment among the elderly. J Soc Psychol. 1984;123(2):291-292.

(18) Reinhardt JP. The importance of friendship and family support in adaptation to chronic vision impairment. J Gerontol Psychol Sci. 1996;51 B(5):268-278.

(19) Fagerström R. Correlation between depression and vision in aged patients before and after cataract operations. Psychol Rep 1994;75:115–25.

(20) Owsley C, McGwin G Jr, Scilley K, Meek GC, Seker D, Dyer A. Impact of cataract surgery on health-related quality of life in nursing home residents. Br J Ophthalmol 2007;91:1359–63.

(21) Polack S. Restoring sight: how cataract surgery improves the lives of older adults. Community Eye Health J. 2008;21(66): 24-25.

(22) Ibid.