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Impaired vision linked to lower mental and physical health

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‘There is no doubt – and there’s plenty of research to back it up – that people who have cataracts or low vision have more depression, more social isolation, less independence, more falls and fractures and less ability to drive.
 
‘Those things all work together to play on your mental health.’
 
Dr Peter Sumich, Vice-President of the Australian Society of Ophthalmologists and a cataract and refractive surgeon, is talking to newsGP following the release of new research published in JAMA Ophthalmology.
 
The research, which included a cross-sectional study of nine systematic reviews published between 2010 and 2020, found there is a ‘consistent’ association between vision impairment, eye diseases, and reduced quality of life.
 
Dr Sumich says these findings fit with what he experiences every day in clinical practice.
 
‘You can visibly see the improvement you make to people when you do their cataracts, in all those respects,’ he said.
 
Melbourne Laureate Professor Hugh Taylor is the past president of the International Council of Ophthalmology, the Harold Mitchell Professor of Indigenous Eye Health at the University of Melbourne and previous Head of the Department of Ophthalmology at the University of Melbourne.
 
He told newsGP he is also not surprised by these results.
 
‘It confirms data that we generated 25 years ago that showed that those who were visually impaired are three times more likely to have depression, eight times more likely to have a fractured neck or femur, two-and-a-half times as likely to die as people with normal vision, and they’re much less likely to be employed,’ he said.
 
Professor Taylor says this is the case for people who are classified as blind, and those with low levels of vision. He believes having low vision has ‘very severe socioeconomic impacts on the individual, their family and their community as a whole’.
 
And yet, he does not believe there is significant understanding in the community about vision loss and its impact.
 
‘There’s a great disregard in our community for the importance and frequency of vision loss,’ he said.
 
‘Many people just brush off vision loss and visual disability as just something that’s not really a problem.’
 
Professor Taylor says there seems to be a pervasive attitude that people with vision loss should ‘just get a pair of glasses and they’ll be able to see’.
 
While the research found poor vision was associated with lower wellbeing, it also noted that timely interventions could improve such measures.
 
Out of 33 unique interventions investigated, 25 were found to ‘improve quality of life compared with baseline measurements or a group receiving no intervention’.
 
‘Seventy-five per cent of ophthalmic interventions evaluated had evidence of a positive outcome on quality of life,’ the authors wrote.
 
‘These findings support pursuing ophthalmic interventions, such as timely cataract surgery and anti-vascular endothelial growth factor therapy, for common retinal diseases, where indicated, to improve quality of life for millions of people globally each year.’
 
Professor Taylor supports such measures, saying they result in an incredible difference in people’s functioning and quality of life and are also ‘extraordinarily cost-effective’ measures.
 
Despite this, Professor Taylor is appalled at how long patients often have to wait to receive such care.
 
‘In Australia it’s scandalous that we have these long waits in so many of the public hospitals across the country, so people are forced to have cataract surgery in private or to sit and wait for sometimes years to get public surgery,’ he said.
 
‘And we face a similar problem with intravitrial injections for the treatment of macular degeneration and for the treatment of diabetic retinopathy.
 
‘Again, while we’ve got good services for patients in private, the poorest members of the community are severely disadvantaged by the lack of public eye-care services.’
 
Professor Taylor says one of the first steps needed to address these issues lies in ensuring patients receive adequate visual assessments.
 
He says GPs should assess visual capability as part of their health checks and that it is a mandatory part of the 715 health check for Aboriginal and Torres Strait Islander patients.
 
Professor Taylor says it is also imperative that clinicians ensure any patient who has diabetes receives regular eye examinations.
 
‘For non-Indigenous Australians, that should be an eye exam once every two years, and for [Aboriginal and Torres Strait Islander people] that needs to be once a year,’ he said.
 
‘Now there’s also a Medicare number that’s been out for four or five years to cover retinal photography to screen for diabetic retinopathy, and that can be done in general practices or wherever, or else a referral should be made to an optometrist or an ophthalmologist for an eye exam.’
 
Despite clear guidelines, Professor Taylor says screening targets are not being met.
 
‘Overall, probably only about half the people with diabetes are getting the eye exam that they should have, and for Indigenous people it’s probably only one in four who are getting the annual eye exam they should have,’ he said.
 
‘For [Aboriginal and Torres Strait Islander people], we really need to make sure that their patient journey is properly managed and they don’t fall through the cracks.
 
‘The same goes for other disadvantaged and migrant communities, to make sure that when the referral is made, people that need support get the support they need to actually get the referral done.’
 
The consequences of patients not receiving such care is devastating, Professor Taylor explains.
 
‘At this stage, my colleagues who deal with retinal problems are continuing to see people who are going blind from diabetic eye disease that should have been picked up and treated years before,’ he said.


Professor Hugh Taylor says it is ‘scandalous’ how long Australian patients in public hospitals are forced to wait for procedures such as cataract surgery.

While appropriate screening, management and support is needed for patients, Dr Sumich also wants clinicians to move past a reliance on outdated screening measures.
 
‘I would say the Snellen chart is an outdated measure of vision now in modern times because it only tells you one thing, which is the ability to resolve high contrast black on white [images] as some form of objective measurement, but it doesn’t tell you about the subjective vision a patient has,’ he said.
 
‘The Snellen vision [chart] is such a low-grade measure of vision compared to [assessing] colours, contrasts, textures and light sensitivity.’
 
Instead of relying on a Snellen chart to assess a patient’s visual acuity, Dr Sumich says it is far preferable to take a thorough history about their vision.
 
Questions should include information about a patient’s:

• night vision
• driving vision
• presence of glare from oncoming headlights or afternoon sun
• ability to see in the dark
• experience of colours and whether they appear dulled
• ability to assess textures
• reading speed and whether that has been reduced.

‘They’re far more sensitive questions and more relevant to real life than the Snellen vision [chart],’ Dr Sumich said.
 
While the research advocates for timely intervention, and Professor Taylor agrees it is important that patients who are at risk of losing vision receive prompt care, Dr Sumich says it is also vital to treat each patient on an individual basis.
 
‘You’ve got to remember that every patient has a different visual demand,’ he said.
 
‘What might not suit a patient who is 70 but still a company director using screens would be quite fine for a person who’s 70 and just potters around gardening tomatoes.
 
‘Vision always has to be compared to the denominator, which is really a patient’s visual demand and what they need.’
 
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