62 newly diagnosed cases of moderate to severe primary glaucoma were recruited from the out - patient department and glaucoma clinics of a tertiary care center in new delhi , india .
patients with characteristic changes in the optic nerve head and corresponding glaucomatous visual field defects on standard automated perimetry were included in the study .
all patients had best corrected visual acuity of at least 20/200 in the better eye , were over 40 years of age and were conversant in hindi or english .
exclusion criteria included subjects with history of previous treatment for glaucoma ; vision < 20/200 in better eye ; presence of other comorbid ocular conditions , e.g. , age - related macular degeneration , cataract , optic neuropathy other than glaucoma , that could potentially contribute to visual loss ; chronic systemic diseases that could significantly affect qol , e.g. , diabetes , arthritis , coronary artery diseases , cerebrovascular diseases , collagen vascular disorders , history of any ocular surgery in previous 3 months ; deaf or communication impaired ; and physically disabled individuals .
eligible patients underwent a thorough history and ocular examination including evaluation of visual acuity ; slit lamp biomicroscopy , intraocular pressure ( iop ) assessment with goldmann applanation tonometer ; gonioscopy using goldmann two - mirror gonioscope ; and optic nerve head evaluation using a 90 d lens .
visual fields examination was performed using the humphrey visual field analyzer ( humphrey instruments inc . , allergan humphrey , san leandro , ca ) using the swedish interactive threshold algorithm 302 .
the patients were categorized with respect to the severity of glaucoma according to the hodapp  parrish  anderson classification .
sixty healthy control subjects with no ocular or systemic disease visiting the hospital for refractive error were included .
the controls were age - matched with the glaucoma cases and were evaluated in a similar manner .
the ind vfq33 is a 33-item questionnaire comprising of 33 items in three domains ( annexure ) .
the general functioning elicited items related to distance vision , near vision , ambulation , night vision , dark adaptation , color vision , depth perception . the psychosocial impact domain related to the feelings of the patient related to low vision , e.g. , whether the subject feared going out at night , was he / she a burden on their family or fear of losing the remaining vision . finally , visual symptoms domain described most common visual symptoms like glare , discomfort , and blurring .
general functioning ( domain 1 ) had 21 items ( q1-q21 ) , a range of response varied from 1 to 5 giving a total range for domain 1 ( 21105 ) .
psychosocial impact ( domain 2 ) and visual symptoms ( domain 3 ) had 5 items ( q22-q26 ) and 7 items ( q27-q33 ) , respectively .
domain 2 and domain 3 had 14 as the range of response with a total score of responses varying from 5 to 20 in psychosocial impact and 128 in visual symptoms domain .
the summary scores from each domain were added to give a total qol score with a minimum score of 33 and maximum 153 . the higher the score , the worse the qol .
the mean total qol score of controls and glaucoma patients at each visit was divided into quartiles viz .
no difficulty ( < 25% ) , mild difficulty ( 25%  50% ) , moderate difficulty ( > 5075% ) and severe difficulty ( > 75% ) with cut - off score of 3338 , 3844 , 4473 and > 73 respectively . the questions were translated and back - translated to the native language , hindi , for standardization .
the ind - vfq33 questionnaire across the three domains was administered to the subjects , by a single investigator ( va ) in the native language .
the evaluation included ophthalmological work - up including visual acuity assessment , slit lamp biomicroscopy , measurement of iop , optic disc assessment and repeat visual field testing using the same algorithm .
qol assessment was repeated using ind - vfq33 questionnaire , this being administered by the same investigator ( va ) in same language as done at the initial visit .
the responses were entered into microsoft excel 2007 data sheet and statistical analysis was done using stata 11 19852011 statacorp lp ( stata press , texas , usa ) .
the mean qol scores of glaucoma patients obtained were compared with that of controls using the unpaired t - test .
multiple linear regression was used to assess significant factors affecting the qol at baseline and 3 months after treatment .
factors like age , sex , visual acuity in the better eye , iop in the better eye , glaucoma severity and number of medications used were included as these may affect the qol of the patient .
correlation values between visual acuity in the better eye , presenting iop , glaucoma severity and total qol score were obtained at baseline and at 3 months .
the ind vfq33 is a 33-item questionnaire comprising of 33 items in three domains ( annexure ) .
the general functioning elicited items related to distance vision , near vision , ambulation , night vision , dark adaptation , color vision , depth perception . the psychosocial impact domain related to the feelings of the patient related to low vision , e.g. , whether the subject feared going out at night , was he / she a burden on their family or fear of losing the remaining vision . finally , visual symptoms domain described most common visual symptoms like glare , discomfort , and blurring .
general functioning ( domain 1 ) had 21 items ( q1-q21 ) , a range of response varied from 1 to 5 giving a total range for domain 1 ( 21105 ) .
psychosocial impact ( domain 2 ) and visual symptoms ( domain 3 ) had 5 items ( q22-q26 ) and 7 items ( q27-q33 ) , respectively .
domain 2 and domain 3 had 14 as the range of response with a total score of responses varying from 5 to 20 in psychosocial impact and 128 in visual symptoms domain .
the summary scores from each domain were added to give a total qol score with a minimum score of 33 and maximum 153 . the higher the score , the worse the qol .
the mean total qol score of controls and glaucoma patients at each visit was divided into quartiles viz .
no difficulty ( < 25% ) , mild difficulty ( 25%  50% ) , moderate difficulty ( > 5075% ) and severe difficulty ( > 75% ) with cut - off score of 3338 , 3844 , 4473 and > 73 respectively .
the questions were translated and back - translated to the native language , hindi , for standardization .
the ind - vfq33 questionnaire across the three domains was administered to the subjects , by a single investigator ( va ) in the native language .
patients were reassessed at 3 months following the start of the ocular hypotensive therapy . the evaluation included ophthalmological work - up including visual acuity assessment , slit lamp biomicroscopy , measurement of iop , optic disc assessment and repeat visual field testing using the same algorithm .
qol assessment was repeated using ind - vfq33 questionnaire , this being administered by the same investigator ( va ) in same language as done at the initial visit .
the responses were entered into microsoft excel 2007 data sheet and statistical analysis was done using stata 11 19852011 statacorp lp ( stata press , texas , usa ) .
the mean qol scores of glaucoma patients obtained were compared with that of controls using the unpaired t - test .
multiple linear regression was used to assess significant factors affecting the qol at baseline and 3 months after treatment .
factors like age , sex , visual acuity in the better eye , iop in the better eye , glaucoma severity and number of medications used were included as these may affect the qol of the patient .
correlation values between visual acuity in the better eye , presenting iop , glaucoma severity and total qol score were obtained at baseline and at 3 months .
the glaucoma subjects and the control population were well matched for age , gender and literacy rates ( p = 0.71 , 0.91 and 0.18 respectively ) .
better eye logmar visual acuity was 0.35  0.25 and 0.08  0.11 in glaucoma patients and controls respectively ( p < 0.001 ) .
glaucoma subjects had significantly higher baseline iop in the better eye than the control population ( 25.4  6.6 vs. 11.6  2.1 mm of hg respectively , p < 0.001 ) .
demographic characteristics of glaucoma patients and controls a comparison of ind - vfq33 total and domain wise scores is provided in table 2 .
there was a significant difference between the two groups with respect to the mean total qol scores , general functioning domain , psychosocial impact and visual symptoms ( p < 0.001 ) .
as shown in table 3 , the total mean score increased from 74.8 to 78.3 ( p < 0.001 ) on repeating the assessment 3 months after initiating the anti - glaucoma therapy suggesting worsening of qol .
comparison of baseline qol scores in glaucoma patients and controls qol scores of glaucoma patients at baseline and 3 months multiple linear regression analysis was used to assess the effect of various factors on the qol as assessed with the ind - vfq33 questionnaire [ table 4 ] .
better eye visual acuity was found to have a significant contribution to the qol scores , both at baseline and after 3 months of starting ocular hypotensive therapy ( p < 0.001 and < 0.05 respectively ) .
it was also noted that the use of more than two ocular hypotensive medications was significantly related to poor qol at 3 months assessment ( p < 0.05 ) .
multiple regression analysis showing the correlation of factors and qol among glaucoma subjects table 5 gives a list of items and response scores that were significantly different between the glaucoma and control subjects .
the general functioning domain showed that most of the glaucoma patients had significant difficulty in ambulation , night vision , recognition , and dark adaptation as compared to controls .
most glaucoma patients were frightened to go out at night and were worried that they may lose their remaining vision .
problems of glare and low vision were also significantly higher in glaucoma patients than controls .
a comparison of commonly reported problems in glaucoma patients and their statistical significance as compared to control subjects table 6 elaborates the patient parameters and qol scores across the primary open - angle glaucoma ( poag ) and primary angle closure glaucoma ( pacg ) population as included in the study .
these groups differed significantly in the visual acuity at baseline and at 3 months , being worse in the pacg population ( p < 0.001 ) .
the mean iop and mean glaucoma severity as seen by the visual field mean deviation scores were comparable across the two groups .
pacg patients had worse qol scores than the poag population both at baseline and at 3 months after initiating ocular hypotensive medications ( p = 0.12 and 0.09 respectively ) , however , the difference did not reach statistical significance .
this is the first study that evaluates the vision related qol in newly diagnosed glaucoma patients using a questionnaire developed and validated specifically for the population of the indian subcontinent .
have earlier validated this questionnaire for vision related qol in 273 cataract patients in southern parts of india .
they noted that patients with severe visual impairment and blindness reported significantly worse vision - specific mobility and activity limitation ( mean change 18.82 , p = 0.007 and 29.48 , p < 0.001 respectively ) compared to those with no visual impairment . nelson et al .
have developed a glaucoma specific gql-15 scale , and defined the vision related problems perceived by glaucoma patients , e.g. , peripheral field , color vision , glare , dark adaptation , which are well covered in the ind - vfq33 questionnaire .
this study shows that subjects with glaucoma had worse qol as compared to control population .
the fact that this further worsened after initiation of medical therapy has some pertinent implications .
this highlights that the diagnosis of glaucoma , a chronic sight - threatening condition that may require life - long therapy , may have a significant psychological impact on a patient .
this should be identified , acknowledged and managed by appropriate disease - related education and counseling .
our results are similar to those reported by nelson et al . where they have noted a statistically significant decrease in performance - related qol between normal subjects and all groups of glaucoma patients . in another study , goldberg et a1 .
also noted that patients with glaucoma had significantly poor qol as compared to subjects without glaucoma .
we noted that in patients with worse visual acuity and those who had to be started on more than two medications , qol further worsened after initiation of medical therapy .
this in turn highlights the importance of educating the patients about the nature of the disease and ensuring drug compliance despite a perceived deterioration in symptoms after starting antiglaucoma medications .
a comparison between poag and pacg subjects suggested a possible worse qol in the latter .
a number of studies have elaborated on the significant problems encountered by subjects with glaucoma .
reported that activities involving glare , dark adaptation , central and near vision , peripheral vision , and outdoor mobility were most problematic for patients with glaucoma . in another study , mckean - cowdin et al . noted that persons with visual field loss had the greatest difficulty with driving activities , dependency , mental health , distance vision , and peripheral vision
wu et al . reported that the presence of open - angle glaucoma was significantly associated with lower scores for distance activities , mental health , and color and peripheral vision .
showed that difficulty with bright lights , and with light and dark adaptation ; were the most frequently reported symptoms related to visual function in glaucoma patients .
these findings are comparable to the results obtained in our study whereby glaucoma subjects were noted to have significant problems in activities which involved near and distance vision , night vision , ambulation , dark adaptation , color vision and glare .
both worse eye and better eye visual acuity have been independently associated with poor qol .
we noted that the decrease in better eye visual acuity was associated with worse qol at baseline and at 3 months .
they also noted that qol had a significant correlation with better eye visual fields and visual acuity varied from 0.07 to 0.18 , however that the strength of correlation was weaker as compared to our results .
van gestel et al . found a significant relationship between qol and iop in the better eye ( p < 0.001 ) .
have published that both visual field index and visual acuity have a linear correlation with glaucoma - related qol .
however , to assess the qol in patients with primary adult - onset glaucoma , all patients with secondary glaucoma were excluded .
also , the exclusion of patients with cataract attempted to remove the confounding of the results obtained .
second , the effects of economic factors , which are especially important for people residing in developing countries , were not included in the questionnaire .
nonetheless , this study shows the important implication of presence of glaucoma , suggesting that newly diagnosed patients may have manifested symptoms of the disease , and initiation of medical therapy may be associated with further worsening of qol .
thus , eye care providers should take every opportunity to educate patients about the nature of disease .
they should be encouraged to continue with therapy despite no apparent benefits or even worsening of their qol at the outset .
 purpose : to evaluate the impact of initial topical medical therapy on newly diagnosed glaucoma patients using the indian vision function questionnaire ( ind - vfq33).patients and methods : the ind - vfq33 was used to evaluate the quality of life ( qol ) in 62 newly diagnosed patients with moderate to severe primary glaucoma and 60 healthy controls . 
 ind - vfq33 is a 33 item qol assessment tool with three domains : general functioning , psychosocial impact and visual symptoms . 
 the glaucoma patients were started on medical therapy and the qol assessment was repeated after 3 months.results:glaucoma patients ( mean age : 55.6  9.6 years , range 4077 years ) and controls ( mean age : 54.9  6.7 years , 4273 years ) were matched with respect to age ( p = 0.72 ) , gender ( p = 0.91 ) and literacy ( p = 0.18 ) . 
 glaucoma patients had significantly worse qol as compared to controls at baseline across all the three domains ( p < 0.001 ) . 
 3 months after initiation of treatment , the overall qol life significantly worsened from baseline with a decrease in general functioning ( p < 0.001 ) and psychosocial impact ( p = 0.041 ) . 
 visual acuity in better eye significantly co - related to poor qol at baseline ( p < 0.001 ) and at 3 months ( p = 0.04 ) . 
 in addition , the use of > 2 topical medications significantly co - related to poor qol at 3 months ( p = 0.01).conclusions : evaluation using the ind - vfq33 revealed that newly diagnosed glaucoma patients have a significant worsening of qol after initiation of topical ocular hypotensive therapy . 
 this should be an important consideration when educating patients about the disease and its therapy . 
Patients and Methods
Quality of life assessment
Follow-up visit
Statistical analysis
Results
Discussion