Glaucoma and Associated Visual Acuity and Field Loss Significantly Affect Glaucoma-Specific Psychosocial Functioning Errol W. Chan, MBBS, FRCOphth, 1,2 Peggy P.C. Chiang, MIPH (Hons), PhD, 2,3 Jiemin Liao, MA, 1,2 Gwyneth Rees, MSc, PhD, 3 Tien Y. Wong, FRCS, PhD, 1,2,3,4 Janice S.H. Lam, MBBS, 1,2 Tin Aung, FRCS, PhD, 1,2,4 Ecosse Lamoureux, MSc, PhD 2,3,4 Objective: To examine the impact of glaucoma and visual acuity (VA) and visual field (VF) losses on psy- chosocial functioning (PF). Design: Cross-sectional study. Participants: We compared PF between 192 participants with bilateral glaucoma with VA or VF losses and 40 controls from a tertiary eye hospital clinic in Singapore. Methods: Glaucoma was defined using the Hodapp-Anderson-Parish criteria. Four psychosocial outcomes of the Glaucoma Quality of Life 36 questionnaire were psychometrically assessed using Rasch analysis. Multi- variate regression was performed to determine the independent impact of glaucoma and VA and VF losses on PF. The impact of VA and VF on PF were evaluated by restricted cubic spline analysis. Main Outcome Measures: Anxiety, self-image, psychological well-being, and confidence in health care. Results: The mean age of participants was 66.211.0 years, and 63% were male. In the better eye, VA and mean deviation were Snellen 20/25 and 8.896.52 dB, respectively. In multivariate models, glaucoma patients had 63.0% greater anxiety (95% confidence interval [CI], 66.0% to 61.2%; P < 0.001), 71.0% lower self-image (95% CI, 74.1% to 68.5%; P < 0.001), 38.3% less psychological well-being (95% CI, 37.4% to 39.0%; P < 0.001), and 32.4% reduced confidence in health care than patients without glaucoma. The worst VA and VF categories had the most reduced PF (range, 26.0% to 81.5%; P < 0.001 for all associations) compared with controls. With worsening VA, there was a linear increase in anxiety (P ¼ 0.009) and decrease in self-image (P ¼ 0.005). With worsening VF from 0 to 12.1 dB (P ¼ 0.003), anxiety increased before plateauing. Self-image decreased as VF worsened from 0 to 10 dB (P < 0.001), and confidence in health care decreased when VF worsened from 0 to 9.3 dB (P ¼ 0.008). However, self-image and confidence in health care actually improved at greater levels of VF loss beyond these thresholds. Conclusion: Glaucoma negatively affects PF. Early stage glaucoma with mild VF loss adversely affects anxiety, self-image, and confidence in health care. As VA worsens in advanced glaucoma, anxiety further in- creases and self-image deteriorates. Ophthalmologists and glaucoma patients need to be aware that both VA and VF losses at different stages of glaucoma negatively impact PF. Ophthalmology 2015;122:494-501 ª 2015 by the American Academy of Ophthalmology. Supplemental material is available at www.aaojournal.org Glaucoma is a leading cause of visual impairment and blindness worldwide, and the prevalence is expected to in- crease. 1,2 In Singapore, the prevalence of glaucoma ranges between 2% and 3.4%. 3e5 Glaucoma adversely affects a patient’s overall health-related quality of life (HRQoL), 6,7 as well as specific activities such as mobility, reading, and driving. 8e12 However, the psychological, social, and emotional burdens of glaucoma are less clearly understood because of limited and equivocal evidence. 13e22 Psychoso- cial functioning (PF) represents a key aspect of the World Health Organization’s conceptualization of HRQoL 23 and refers to psychological and social effects of the disease on the patient. It distinctly differs from the ability to perform vision-related tasks, 6e12 that is, vision-specific functioning, which has been the focus of HRQoL research in ophthal- mology to date. Reduced PF is an increasingly recognized clinical consequence of chronic medical illness and nega- tively impacts an individual’s overall physical and mental health. 24e26 Therefore, understanding how PF is affected in glaucoma patients is important and may determine when additional treatment and/or psychosocial therapy is indicated. 27 Visual acuity (VA) and visual field (VF) losses are the most commonly used clinical indices to assess visual function in 494 Ó 2015 by the American Academy of Ophthalmology Published by Elsevier Inc. http://dx.doi.org/10.1016/j.ophtha.2014.09.030 ISSN 0161-6420/14