Some problems matter more than others when assessing quality-of-life factors.

Although a general association between vision loss and anxiety or depression has long been recognized, a new study clarifies the kinds of visual deficits that most affect mental health.

While objective visual acuity may be measured using the familiar eye chart, functional aspects of vision relate to a person’s ability to conduct activities of daily living.

“Our study focused on these functional aspects of vision, the visual ability to participate in daily tasks,” said Tyler Pfister, a fourth-year medical student at Vanderbilt University Medical Center.

He worked with Sapna Gangaputra, M.D., an associate professor of ophthalmology, and Vanderbilt psychiatry faculty members on the research. Pfister earned a Knights Templar Eye Foundation award that enabled him to present his work at a meeting of the Association for Research in Vision and Ophthalmology Foundation for Eye Research in 2022.

“Problems with communication raise the risk of anxiety and depression.”

People Accept Poor Vision

“Many people assume that seeing or hearing poorly as they age is normal and acceptable,” Gangaputra said. “They tolerate living with blurred vision when they could be seeing clearly with appropriate visual aids such as glasses or cataract surgery.”

People who never wore glasses as children are especially prone to avoid them later in life, she has observed. The ophthalmologist stressed that it isn’t an access-to-care issue. Affordable reading glasses are readily available, and many insurance plans offer vision coverage.

Seeing Poorly Promotes Disability

In their recent study, the team explored the causal relationships between visual impairment and functional disability that may predispose someone to developing depression, Pfister explained.

“We expected all the different categories of ADLs [activities of daily living] and IADLs [ instrumental activities of daily living] would contribute in some regard, and mostly that was true,” said Pfister.

However, certain activities stood out to researchers examining the ADLs individually.

 Visual difficulty affecting bathing, mobility, dressing and toileting contributed to higher rates of both anxiety and depression.

“We also saw that problems with communication raise the risk of anxiety and depression,” he explained.It wasn’t text-based communication that seems to matter so much. It may instead be the ability to read other people’s nonverbal cues.”

Impairments in far vision seemed to exert stronger effects on mental health than impairments in near vision.

“One surprise was the finding that a person’s inability to handle their own transportation did not contribute to vision-related anxiety or depression,” he said, offering the possible explanation that many people with visual impairments continue to drive. “The ability to drive is so ingrained in the U.S. population that many find it difficult to allow others to take over the task for them.”

A Large Dataset

The research team worked with data from nearly 16,000 U.S. adults aged 18 or older gleaned from the 2016 National Health Interview Survey. To explore questions of causality, they used a technique called structural equation modeling to conduct a pathways analysis.

“This approach allowed us to assess the direct and indirect effects where different types of visual impairments impact psychological disorders,” Pfister said.

In a recent report, one in four adults with vision loss reported either anxiety or depression.

As people are living longer, researchers predict that visual impairment incidence will continue to rise, with many such problems are related to aging. Some say that the number of individuals with moderate-to-severe visual impairment will double and that blindness will triple over the next 30 years.

While their work addresses widespread problems, Gangaputra is also studying ways to help patients with rare, hard-to-treat disorders, such as children with uveitis, which can cause blindness. She is one of fewer than 100 dedicated uveitis specialists in the U.S.

“They also need to ask, ‘Have you had your eyes checked? Have you seen an eye doctor?’”

Role for Primary Care

Assessing visual impairments and connecting patients with resources to deal with them seem to be tasks well situated for primary-care doctors, Pfister stated.

“Primary-care providers don’t routinely do vision tests during visits,” Pfister said. “Vision often falls by the wayside, and it’s up to the patient to seek testing and obtain care.”

This may be delayed when visual changes are slow in progressing, as patients may not notice until they have lost a significant amount of vision.

Assessing a patient’s ability to carry out activities of daily living is another precaution that is not typically a routine part of visiting the ophthalmologist, he noted.  Still, clinicians should be aware of the impact that different types of visual limitation can have on a person’s life and mental health.

Patients need education about the connection between seeing well and enjoying a good quality of life, the researchers stressed. Primary care providers routinely assess patients for anxiety and depression, smoking and seatbelt use, but less often the status of their vision.

“They also need to ask, ‘Have you had your eyes checked? Have you seen an eye doctor?’” Gangaputra said.

About the Expert

Sapna Gangaputra, M.D.

Sapna Gangaputra, M.D., M.P.H., is an associate professor of ophthalmology at Vanderbilt University Medical Center and specializes in uveitis, medical retina and clinical research.

Tyler Pfister

Tyler Pfister is a medical student at Vanderbilt University School of Medicine. His research interests include understanding how ocular disorders impact quality of life and improving ophthalmic medical education.