Korean J Ophthalmol > Volume 36(5); 2022 > Article
Ji, Kim, Baek, Kim, Nam, Lee, Lee, Jeong, and Ha: Perceived Stress Levels and Associated Factors in Adult Patients with Primary Open-angle Glaucoma: A Prospective Survey Study



To investigate adult primary open-angle glaucoma (POAG) patients’ perceived stress levels and to examine the associations with their clinical characteristics.


Sixty-seven POAG patients, excluding those meeting the exclusion criteria (retinal or neurological disease diagnoses) comprised the study population. A validated questionnaire, namely Perceived Stress Scale-10 (PSS-10), was used to assess stress level. Additional data on glaucoma surgery history, medical benefit receipt, comorbidities, and daily antiglaucoma medication number were collected. The clinical characteristics of high (PSS-10 ≥15) and low stress (PSS-10 <15) patients and the risk factors associated with high stress level were subjected to a multivariable logistic regression analysis.


The patients were 56.8 ± 12.6 years of age on average, and 29 (43.3%) were female. The mean PSS-10 level was 13.5 ± 5.3 (range, 1-27) for the entire patient group; 31 patients (46.3%) were in the high stress group. In the high stress group relative to the low stress group, best-corrected visual acuity in the better eye was lower (p = 0.044) and the visual field defects, in both eyes, were more severe (better eye, p = 0.005; worse eye, p = 0.026). A logistic regression analysis indicated that severe visual field defect in the better eye (odds ratio, 1.159; 95% confidence interval, 1.016-1.323; p = 0.028) and lower best-corrected visual acuity in the better eye (odds ratio, 4.707; 95% confidence interval, 0.580-6.189; p = 0.072) were both likely to associated with high stress level in patients with POAG.


These findings suggest an association between severe visual function loss and higher mental stress level in POAG patients. Stress level, therefore, might be an important consideration in POAG patient management.

Glaucoma, a degenerative chronic optic neuropathy, is the second most common cause of blindness in the world [1]. Given its chronic nature and the possibility of its leading to irreversible blindness, not to mention the inherent side effects of its treatment, glaucoma often becomes psychologically burdensome for patients [2-4].
Many studies have shown that anxiety, depression, or mental stress status can accelerate chronic disease courses. Stress, for example, exacerbates cardiovascular, gastrointestinal, or respiratory disorders [5-8]. Emotional responses to external stimuli trigger neurotransmitter secretion and, subsequently thereby, autonomic nervous system (ANS) stimulation, which impacts multiple organs [9]. The ANS, which also can be affected by stress level, might be implicated glaucoma development and/or progression. For patients with imbalanced ANS, for example, blood pressure fluctuation and hypotension tend to cause optic nerve blood-flow disorder or ischemia [10-13].
Few studies have investigated the association of mental stress with glaucoma [14-16]. The aim of the present study, then, was to measure adult primary open-angle glaucoma (POAG) patients’ perceived stress levels using a validated questionnaire and to examine associations with their clinical characteristics.

Materials and Methods

Ethics statement

This single-center cross-sectional study was undertaken at Jeju National University Hospital. The study protocol was approved by the Institutional Review Board of Jeju National University Hospital (No. 2020-12-015) and adhered to the tenets of the Declaration of Helsinki. All participants provided their written informed consent.

Study subjects

For inclusion in the study, glaucoma patients were required to satisfy the following characterization of POAG: presence of glaucomatous optic disc changes manifesting as diffuse or localized notching, thinning, or both; retinal nerve fiber layer defect; glaucomatous visual field (VF) defect corresponding to structural change; and open angle (as confirmed by gonioscopic examination). Glaucomatous VF defect was defined as (1) glaucoma hemifield test values outside normal limits; (2) three or more abnormal contiguous points with probability of p < 0.05, of which one or more points has pattern deviation of p < 0.01; or (3) pattern standard deviation of p < 0.05. VF defects were confirmed based on two consecutive reliable tests (fixation loss rate, ≤20%; false-positive and false-negative error rates, ≤25%). We excluded patients suspected of secondary glaucoma or angle-closure glaucoma. Subjects were further excluded if they had any retinal or neurologic disease that could possibly affect visual acuity or VF examination results.
All of the enrolled patients underwent an ophthalmological examination including best-corrected visual acuity (BCVA) assessment using the Snellen chart, slit-lamp biomicroscopy, dilated fundus examination, Goldmann applanation tonometry (Haag-Streit, Koniz, Switzerland), digital color stereo disc photography, red-free retinal nerve fiber layer photography, optical coherence tomography (OCT; Cirrus HD-OCT, Carl Zeiss Meditec, Dublin, CA, USA), and the SITA program test (central 24-2) of the Humphrey Visual Field (HFA 750i; Carl Zeiss Meditec).
Patients’ treatment history regarding systemic disorders such as hypertension, diabetes mellitus, chronic diseases of the heart, lung or liver, autoimmune diseases, cancer, or psychiatric diseases was thoroughly investigated. We considered diseases included in the Charlson Comorbidity Index as possible comorbid conditions affecting perceived stress levels. The index included the following 16 categories of disease: myocardial infarction, congestive heart failure, peripheral vascular disease, cerebrovascular accident or transient ischemic attack, dementia, chronic obstructive pulmonary disease, connective tissue disease, peptic ulcer disease, liver cirrhosis or chronic hepatitis, diabetes mellitus, hemiplegia, chronic kidney disease, solid tumor, leukemia, lymphoma, and AIDS [17]. In terms of diabetes mellitus, a poorly controlled condition defined as glycosylated hemoglobin >7% at the time of study enrollment was considered as a significant comorbidity [18]. The psychiatric diseases investigated in this study included the following: anxiety disorders, mood disorders, trauma-related and stressor-related disorders, feeding and eating disorders, disruptive impulse-control and conduct disorders, obsessive-compulsive and related disorders, as well as schizophrenia spectrum and other psychotic disorders [19].

Perceived stress questionnaire

Participants filled out Perceived Stress Scale-10 (PSS-10), a validated self-administered questionnaire, preparatory to assessment of their psychological stress. PSS-10 is a widely used, psychometrically validated and reliable measure of psychological stress [20]. PSS-10 includes 10 items, down from the original 14 (PSS-14), four items (questions 4, 5, 12, and 13) having been removed owing to low factor relativity [21]. PSS-10 questions concern moods and thoughts experienced during the previous month, according to two factors: “general stressors” and “ability to cope.” Subjects were asked to indicate how often they found themselves in such situations [22].
In PSS-10, each item is measured on a Likert scale (0, never; 1, almost never; 2, sometimes; 3, fairly often; 4, very often), total scores ranging from 0 (no stress) to 40 (high stress). The score range is as follows: ≤14, below or at average perceived stress; ≥15, above average perceived stress [23]. The questionnaire was administered in a validated Korean version [24]. Participants completed the questionnaires at the clinic, or it was verbally administered to those lacking functional literacy and/or upon request. The full set of PSS-10 questions is listed in Table 1 and Supplementary Table 1.

Statistical analysis

Data are presented as mean ± standard deviations, except stated otherwise. Parametric or nonparametric tests were used according to the normality of the data (as assessed by Kolmogorov-Smirnov testing). The independent t-test and chi-square test for independent samples were used in order to assess the differences between the high and low stress groups. Logistic regression analyses were performed to identify clinical characteristics associated with high-level stress. Factors with a p-value of <0.10 as determined in the univariate model were included in the multivariate model. A p-value of <0.05 indicated statistical significance. All of the statistical analyses were performed with IBM SPSS ver. 27.0 (IBM Corp., Armonk, NY, USA). As a sensitivity analysis, we repeated the earlier analyses by excluding patients with surgical history.


Initially, 68 POAG patients who had met the eligibility criteria were enrolled. Among them, one withdrew their consent to participate. Thus, the final cohort number was 67.

Demographic and clinical characteristics of study subjects

The subjects’ mean age was 56.8 ± 12.6 years (range, 22-77 years). Among them, 38 (56.7%) were male and 29 (43.3%) were female. The majority of patients (n = 57, 85.1%) were cases of bilateral glaucoma involvement, 10 (14.9%) being unilateral. Most patients (n = 61, 91.0%) had a baseline intraocular pressure (IOP) lower than 21 mmHg. The average VF mean deviation was, in the better eye, -5.5 ± 6.5 dB, and in the worse eye, -9.9 ± 8.1 dB. A total of five patients (7.5%) had severe visual impairment (<6 / 60) in their better eye. Three had advanced VF defect, and the other two both had center-involving VF defect with moderate cortical cataract. The mean PSS-10 for the entire patient group was 13.5 ± 5.3 (range, 1-27). The patients’ demographic and clinical characteristics are summarized in Table 2.

Demographic and clinical characteristics of low and high stress POAG patients

Among the 67 POAG patients, 36 (53.7%) were in the low stress group (PSS-10 range, 1-14) and 31 (46.3%) were in the high stress group (PSS-10 range, 15-27). Compared with the low stress group, the high stress group had a lower BCVA (logarithm of the minimum angle of resolution, logMAR) in the better eye (0.04 ± 0.05 vs. 0.14 ± 0.20 log- MAR, p = 0.044) and more severe VF defects, both in the better eye (−3.48 ± 2.95 vs. −8.21 ± 8.46 dB, p = 0.005), and in the worse eye (−7.74 ± 6.26 vs. −12.30 ± 9.38 dB, p = 0.026).
In the low stress group, one patient had undergone glaucoma surgery, two had received medical benefits, and 13 suffered underlying diseases. In the high stress group, three patients had undergone glaucoma surgery, one had received medical benefits, and 12 patients were afflicted with underlying diseases. None of these intergroup differences were statistically significant (p = 0.235, p = 0.468, and p > 0.999, respectively). The number of IOP-lowering eye drops taken per day was higher in the high stress group, but the difference was not statistically significant (3.7 ± 2.3 vs. 4.3 ± 2.8, p = 0.439). One patient diagnosed with schizophrenia was included in the low stress group, and the high stress group included one patient with panic disorder and one with depression. The overall results of the intergroup comparison by PSS-10 are summarized in Table 3.

Factors associated with high perceived stress in POAG patients

The factors found to be associated with high perceived stress level were analyzed by both univariable and multivariable analyses. The univariable analysis revealed that male sex (odds ratio [OR], 2.347; 95% confidence interval [CI], 0.856-6.369; p = 0.094), lower BCVA in better eye (per 0.1 logMAR worse; OR, 8.454; 95% CI, 2.260-31.63; p = 0.026), worse VF defect in better eye (OR, 1.178; 95% CI, 1.038-1.337; p = 0.011), and worse VF defect in worse eye (OR, 1.079; 95% CI, 1.008-1.155; p = 0.028) were associated with high stress level.
According to the multivariable logistic regression analysis, worse VF defect in better eye was associated with high-stress risk in POAG patients (OR, 1.159; 95% CI, 1.016-1.323; p = 0.028). Lower BCVA in better eye also was likely to be associated with high-stress risk (OR, 4.707; 95% CI, 0.580-6.189; p = 0.072). The full statistical results with the ORs and CIs are summarized in Table 4.
As a sensitivity analysis, we repeated the analyses by excluding four patients (6.0%) who had undergone glaucoma surgery. We noted that, after accounting for the effects of surgical history, the conclusions were not altered substantially. The results are shown in Supplementary Table 2.


This study investigated adult POAG patients’ perceived stress levels and revealed the clinical risk factors that are associated with high stress level. We found that worse VF defect and lower BCVA in the better eye are likely to be associated with high mental stress.
The relationship between glaucoma patients’ VF loss and quality of life (QoL) has been investigated previously. The Los Angeles Latino Eye Study, a population-based prevalence study on eye diseases, reported that glaucoma patients who had severe VF loss scored lower on QoL than did patients with no or mild VF loss [25]. Wolfram et al. [26] evaluated POAG patients’ general and visual function QoL and found that QoL perception was progressively reduced throughout the disease stages. QoL is defined as an individual’s perception of his or her position in life, both within the context of their culture and value systems and in relation to their goals, expectations, standards, stress, and concerns [27]. Severe VF damage, for example, has a negative impact on daily activities such as driving, walking or reading. It can be considered, therefore, that severe VF loss affects general and/or visual function QoL for glaucoma patients, resulting in high stress levels.
Our study did not evaluate the impact of binocularity or VF-defect location on perceived stress levels. In the study of van Gestel et al. [28], which investigated the relationship between VF loss and health-related QoL in glaucoma patients, binocular VF was almost completely determined by the VF in the better eye. This study also showed the major impact of the better eye in vision-related activities and visual functioning, which was consistent with our findings. However, monocular VF cannot fully reflect the binocular VF in individual patients. Definitely, future research on the relationship between binocular VF and perceived stress is needed.
Both objective and subjective visual impairments are associated with higher perceived stress levels [29]. Visual impairment can directly increase levels of perceived stress by limiting an individual’s ability to engage in daily activities (e.g., mobility, driving, reading, and recognizing people). Such limitations may reduce social interactions, leading to loneliness [30], which is perceived by many as being stressful [31]. Anxiety or fear of becoming blind, moreover, may lead to high stress levels in patients with poor vision [32]. Our study results also indicated that lower BCVA in the better eye was likely to be associated with high levels of stress, though this conclusion did not meet the threshold for statistical significance (p = 0.072). In our logistic regression analysis, notably, greater decrease in BCVA in the better eye showed a higher OR for high-stress risk compared with that of worse VF mean deviation (4.707 and 1.159, respectively). In a study by Richman et al. [33], an objective estimation of vision-specific ability to perform activities of daily living and its correlation to clinical tests was attempted for a group of glaucoma patients. In this study, binocular visual acuity had, as compared with Esterman binocular VF, higher correlations with patients’ ability to perform daily-life actions such as reading in reduced illumination or recognizing facial expressions [33]. These results suggest the possibility that vision is a more important factor in determining visual function QoL and subsequent perceived stress level. However, since advanced VF defects and center-involving defects also can affect vision, the interaction between these two factors should be thoroughly investigated. Also, as our cohort included only a small number of patients (n = 5, 7.5%) with severe visual impairment (<6 / 60), further, larger-sample studies with a wider range of visual acuity are warranted.
Alternatively, it is also possible that stress contributes to glaucoma development and/or deterioration. Stress may in fact be a risk factor for increased cortisol levels, which could negatively impact the brain and eye via ANS imbalance and/or vascular dysregulation [34]. The negative effect of mental stress on treatment adherence, specifically in chronic diseases such as type 2 diabetes mellitus and hypertension, has been reported [35, 36]. Pappa et al. [37] showed psychological distress to be associated with glaucoma patients’ poor treatment compliance. Although the specific impact of noncompliance on clinical outcome still is not well established [38], several studies have found a relation between noncompliance and either high IOP or severe VF loss [39-41]. Stress, furthermore, may lead to unhealthy behavior such as smoking, excessive alcohol consumption, and poor eating habits, which can lead to increased risk of development, or exacerbation, of glaucomatous damage [42,43]. Hence, there may be a vicious cycle wherein glaucoma leads to increased levels of stress, which in turn, aggravates glaucomatous damage, leading to further increased stress levels, and so on.
It has been known that susceptibility to stress and coping styles differ according to sex. Women tend to rate their life events as more negative and less controllable than men [44]. Cohen et al. [45], having analyzed national surveys done more than two decades apart, showed that women consistently reported more stress than did men. A study that evaluated perceived stress levels in uveitis patients correspondingly reported female sex as a significant factor for high PSS-10 score [46]. In our univariate analysis results, male sex tended to show higher stress. Notably, male patients in our study had worse BCVA (0.12 ± 0.19 vs. 0.05 ± 0.06 logMAR) and VF mean deviation (−6.84 ± 7.93 vs. −3.80 ± 3.20) in their better eye relative to female patients, though the differences did not reach statistical significance (both p > 0.05). Thus, this visual function loss would have had a greater influence on male patients’ high PSS-10 score than sex-based differences in susceptibility to stress.
The present study’s findings should be interpreted in the context of its limitations. First, its design is cross-sectional, and the questionnaire utilized is subject to recall bias. PSS consists of questions that refer to the month prior to the questionnaire, and so, reflecting all aspects of a patient’s stress is not possible. In future research, a longitudinal study design would enable better characterization of the association between stress level and glaucomatous damage in patients with POAG. Second, we were not able to evaluate some factors possibly associated with mental stress level, such as living arrangement, smoking status, and personality traits. A more complex measure would have allowed for more detailed statistical analyses of risk factors for high stress level in POAG patients. Third, the enrolled subjects were mostly low-baseline-IOP POAG (91.0% of the subjects had a baseline IOP ≤21 mmHg). Therefore, given that higher IOP levels may be a significant stressor, our results might not be directly applicable to higher-baseline-IOP POAG patients. Fourth, this study did not exclude patients with psychiatric diseases. Acute and chronic stressors play a role in the pathogenesis of numerous psychiatric diseases as well as in the exacerbation of symptoms [47]. Individuals with psychiatric diseases may selectively recall more negative or stressful events that had occurred in the past, resulting in a high or relatively high PSS-10 score. Fifth, the effects of confounding variables could have been exacerbated in the present analysis due to its having included only a modest sample size. Also, our patients were volunteers who had agreed to participate in this study. Therefore, selection bias cannot be ruled out.
In conclusion, this study suggests that severe visual function loss is associated with higher levels of mental stress for POAG patients. This finding offers new insights into the best care of patients with glaucoma. The causal interactions possibly at work between stress and glaucoma need to be addressed by future longitudinal studies.

Supplementary Materials

Supplementary materials are available at https://doi.org/10.334/kjo.2022.0049.
Supplementary Table 1. Korean version of Perceived Stress Scale-10
Supplementary Table 2. Factors associated with high perceived stress in patients with glaucoma




Conflicts of Interest: None.

Funding: None.


1. Kingman S. Glaucoma is second leading cause of blindness globally. Bull World Health Organ 2004;82:887-8.
pmid pmc
2. Jampel HD, Schwartz A, Pollack I, et al. Glaucoma patients’ assessment of their visual function and quality of life. J Glaucoma 2002;11:154-63.
crossref pmid
3. Nelson P, Aspinall P, Papasouliotis O, et al. Quality of life in glaucoma and its relationship with visual function. J Glaucoma 2003;12:139-50.
crossref pmid
4. Spaeth G, Walt J, Keener J. Evaluation of quality of life for patients with glaucoma. Am J Ophthalmol 2006;141(1 Suppl):S3-14.
crossref pmid
5. Suls J, Bunde J. Anger, anxiety, and depression as risk factors for cardiovascular disease: the problems and implications of overlapping affective dispositions. Psychol Bull 2005;131:260-300.
crossref pmid
6. Goldney RD, Ruffin R, Fisher LJ, Wilson DH. Asthma symptoms associated with depression and lower quality of life: a population survey. Med J Aust 2003;178:437-41.
crossref pmid pdf
7. Midenfjord I, Polster A, Sjovall H, et al. Anxiety and depression in irritable bowel syndrome: exploring the interaction with other symptoms and pathophysiology using multivariate analyses. Neurogastroenterol Motil 2019;31:e13619.
crossref pmid pdf
8. Sibelli A, Chalder T, Everitt H, et al. A systematic review with meta-analysis of the role of anxiety and depression in irritable bowel syndrome onset. Psychol Med 2016;46:3065-80.
crossref pmid
9. Hoehn-Saric R, McLeod DR, Funderburk F, Kowalski P. Somatic symptoms and physiologic responses in generalized anxiety disorder and panic disorder: an ambulatory monitor study. Arch Gen Psychiatry 2004;61:913-21.
crossref pmid
10. Shin DY, Jeon SJ, Park HY, Park CK. Posterior scleral deformation and autonomic dysfunction in normal tension glaucoma. Sci Rep 2020;10:8203.
crossref pmid pmc pdf
11. Park HL, Jung SH, Park SH, Park CK. Detecting autonomic dysfunction in patients with glaucoma using dynamic pupillometry. Medicine (Baltimore) 2019;98:e14658.
crossref pmid pmc
12. Pasquale LR. Vascular and autonomic dysregulation in primary open-angle glaucoma. Curr Opin Ophthalmol 2016;27:94-101.
crossref pmid pmc
13. Grassi G. Assessment of sympathetic cardiovascular drive in human hypertension: achievements and perspectives. Hypertension 2009;54:690-7.
crossref pmid
14. Mabuchi F, Yoshimura K, Kashiwagi K, et al. High prevalence of anxiety and depression in patients with primary open-angle glaucoma. J Glaucoma 2008;17:552-7.
crossref pmid
15. Erb C, Batra A, Bromer A, et al. Psychiatric manifestations in patients with primary open-angle glaucoma. Ophthalmologe 1993;90:635-9.
16. Chen YY, Lai YJ, Wang JP, et al. The association between glaucoma and risk of depression: a nationwide population-based cohort study. BMC Ophthalmol 2018;18:146.
crossref pmid pmc pdf
17. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992;45:613-9.
crossref pmid
18. Arosemena CM, Sanchez AJ, Tettamanti MD, et al. Prevalence and risk factors of poorly controlled diabetes mellitus in a clinical setting in Guayaquil, Ecuador: a cross-sectional study. Int J Diabetes Clin Res 2015;2:1-5.
19. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Virginia: American Psychiatric Association; 1994.
20. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.
crossref pmid
21. Zappella M, Biamonte F, Balzamino BO, et al. Relaxation response in stressed volunteers: psychometric tests and neurotrophin changes in biological fluids. Front Psychiatry 2021;12:655453.
crossref pmid pmc
22. Smith KJ, Rosenberg DL, Timothy Haight G. An assessment of the psychometric properties of the perceived stress scale-10 (PSS 10) with business and accounting students. Account Perspect 2014;13:29-59.
23. van Eck M, Berkhof H, Nicolson N, Sulon J. The effects of perceived stress, traits, mood states, and stressful daily events on salivary cortisol. Psychosom Med 1996;58:447-58.
crossref pmid
24. Hong GR, Kang HK, Oh E, et al. Reliability and validity of the Korean version of the Perceived Stress Scale-10 (K-PSS-10) in older adults. Res Gerontol Nurs 2016;9:45-51.
crossref pmid
25. Globe DR, Schoua-Glusberg A, Paz S, et al. Using focus groups to develop a culturally sensitive methodology for epidemiological surveys in a Latino population: findings from the Los Angeles Latino Eye Study (LALES). Ethn Dis 2002;12:259-66.
26. Wolfram C, Lorenz K, Breitscheidel L, et al. Health- and vision-related quality of life in patients with ocular hypertension or primary open-angle glaucoma. Ophthalmologica 2013;229:227-34.
crossref pmid pdf
27. The WHOQOL Group. The World Health Organization Quality of Life assessment (WHOQOL): position paper from the World Health Organization. Soc Sci Med 1995;41:1403-9.
crossref pmid
28. van Gestel A, Webers CA, Beckers HJ, et al. The relationship between visual field loss in glaucoma and health-related quality-of-life. Eye (Lond) 2010;24:1759-69.
crossref pmid pdf
29. Jacob L, Kostev K, Smith L, et al. Association of objective and subjective far vision impairment with perceived stress among older adults in six low- and middle-income countries. Eye (Lond) 2022;36:1274-80.
crossref pmid pdf
30. Verstraten PF, Brinkmann WL, Stevens NL, Schouten JS. Loneliness, adaptation to vision impairment, social support and depression among visually impaired elderly. Int Congr Ser 2005;1282:317-21.
31. Huang LJ, Du WT, Liu YC, et al. Loneliness, stress, and depressive symptoms among the Chinese rural empty nest elderly: a moderated mediation analysis. Issues Ment Health Nurs 2019;40:73-8.
crossref pmid
32. Kolawole OU, Ashaye AO, Mahmoud AO, Adeoti CO. Cataract blindness in Osun state, Nigeria: results of a survey. Middle East Afr J Ophthalmol 2012;19:364-71.
crossref pmid pmc
33. Richman J, Lorenzana LL, Lankaranian D, et al. Relationships in glaucoma patients between standard vision tests, quality of life, and ability to perform daily activities. Ophthalmic Epidemiol 2010;17:144-51.
crossref pmid
34. Sabel BA, Wang J, Cardenas-Morales L, et al. Mental stress as consequence and cause of vision loss: the dawn of psychosomatic ophthalmology for preventive and personalized medicine. EPMA J 2018;9:133-60.
crossref pmid pmc pdf
35. Vasanth R, Ganesh A, Shanker R. Impact of stress on type 2 diabetes mellitus management. Psychiatr Danub 2017;29(Suppl 3):416-21.
36. Alvarez C, Hines AL, Carson KA, et al. Association of perceived stress and discrimination on medication adherence among diverse patients with uncontrolled hypertension. Ethn Dis 2021;31:97-108.
crossref pmid pmc pdf
37. Pappa C, Hyphantis T, Pappa S, et al. Psychiatric manifestations and personality traits associated with compliance with glaucoma treatment. J Psychosom Res 2006;61:609-17.
crossref pmid
38. Olthoff CM, Schouten JS, van de Borne BW, Webers CA. Noncompliance with ocular hypotensive treatment in patients with glaucoma or ocular hypertension an evidence-based review. Ophthalmology 2005;112:953-61.
crossref pmid
39. Ashburn FS Jr, Goldberg I, Kass MA. Compliance with ocular therapy. Surv Ophthalmol 1980;24:237-48.
crossref pmid
40. Granstrom PA. Progression of visual field defects in glaucoma: relation to compliance with pilocarpine therapy. Arch Ophthalmol 1985;103:529-31.
crossref pmid
41. Gurwitz JH, Yeomans SM, Glynn RJ, et al. Patient noncompliance in the managed care setting: the case of medical therapy for glaucoma. Med Care 1998;36:357-69.
42. Laugero KD, Falcon LM, Tucker KL. Relationship between perceived stress and dietary and activity patterns in older adults participating in the Boston Puerto Rican Health Study. Appetite 2011;56:194-204.
crossref pmid pmc
43. Stubbs B, Veronese N, Vancampfort D, et al. Perceived stress and smoking across 41 countries: a global perspective across Europe, Africa, Asia and the Americas. Sci Rep 2017;7:7597.
crossref pmid pmc pdf
44. Matud MP. Gender differences in stress and coping styles. Personal Individ Differ 2004;37:1401-15.
45. Cohen S, Janicki-Deverts D. Who’s stressed? Distributions of psychological stress in the United States in probability samples from 1983-2006 and 2009. J Appl Soc Psychol 2012;42:1320-34.
46. Berlinberg EJ, Gonzales JA, Doan T, Acharya NR. Association between noninfectious uveitis and psychological stress. JAMA Ophthalmol 2019;137:199-205.
crossref pmid pmc
47. Stout SC, Nemeroff CB. Stress and psychiatric disorders. Semin Neurosci 1994;6:271-80.

Table 1
Perceived Stress Scale-10
No. Question
1. In the last month, how often have you been upset because of something that happened unexpectedly?
2. In the last month, how often have you felt that you were unable to control the important things in your life?
3. In the last month, how often have you felt nervous and “stressed”?
4. In the last month, how often have you felt confident about your ability to handle your personal problems?
5. In the last month, how often have you felt that things were going your way?
6. In the last month, how often have you found that you could not cope with all the things that you had to do?
7. In the last month, how often have you been able to control irritations in your life?
8. In the last month, how often have you felt that you were on top of things?
9. In the last month, how often have you been angered because of things that were outside of your control?
10. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

Each item was measured on a Likert scale (0, never; 1, almost never; 2, sometimes; 3, fairly often; 4, very often), total scores ranging from 0 (no stress) to 40 (high stress). The corresponding Korean version is provided in Supplementary Table 1.

Table 2
Clinical characteristics of study patients (n = 67)
Characteristic Value
Age (yr) 56.8 ± 12.6 (32 to 77)
 Male 38 (56.7)
 Female 29 (43.3)
 Better eye 0.09 ± 0.15 (0 to 0.70)
 Worse eye 0.23 ± 0.36 (0 to 1.10)
Intraocular pressure (mmHg)
 Right eye 12.5 ± 2.8 (7.0 to 20.0)
 Left eye 12.2 ± 3.1 (6.0 to 20.0)
Visual field mean deviation (dB)
 Better eye −5.50 ± 6.50 (−30.28 to 0.56)
 Worse eye −9.90 ± 8.10 (−33.06 to −0.82)
Perceived Stress Scale-10 13.5 ± 5.3 (1 to 27)

Values are presented as mean ± standard deviation (range) or number (%).

BCVA = best-corrected visual acuity; logMAR = logarithm of the minimum angle of resolution.

Table 3
Comparison of demographic and clinical characteristics between low and high stress group
Variable Low stress (n = 36) High stress (n = 31) p-value
Baseline factor
 Age (yr) 56.5 ± 13.1 (35 to 77) 57.2 ± 12.1 (32 to 75) 0.816*
  Male 17 (47.2) 21 (67.7)
  Female 19 (52.8) 10 (32.3) 0.091
 Medical benefit recipient 2 (5.6) 1 (3.2) 0.468
Ocular factor
 BCVA (logMAR)
  Better eye 0.04 ± 0.05 (0 to 0.22) 0.14 ± 0.2 (0 to 0.70) 0.044§
  Worse eye 0.14 ± 0.16 (0 to 0.82) 0.33 ± 0.4 (0 to 1.10) 0.145§
 Visual field mean deviation (dB)
  Better eye −3.48 ± 2.95 (−11.46 to 0.56) −8.21 ± 8.46 (−30.28 to 0.55) 0.005*
  Worse eye −7.74 ± 6.26 (−28.90 to −1.05) −12.30 ± 9.38 (−33.06 to −0.81) 0.026*
 Intraocular pressure (mmHg)
  Right eye 12.4 ± 2.7 (10.0 to 20.0) 12.5 ± 3.1 (7.0 to 19.0) 0.855*
  Left eye 12.1 ± 2.9 (6.0 to 19.0) 12.3 ± 3.4 (8.0 to 20.0) 0.789*
 History of glaucoma surgery 1 (2.8) 3 (9.7) 0.235
 No. of eye drops per day 3.7 ± 2.3 (1 to 10) 4.3 ± 2.8 (1 to 10) 0.439§
Comorbidity >0.999
 Uncontrolled diabetes mellitus 3 (8.3) 3 (9.7)
 Cerebrovascular accident 1 (2.8) 0 (0)
 Heart disease 3 (8.3) 2 (6.5)
 Lung disease 2 (5.6) 1 (3.2)
 Liver disease 1 (2.8) 1 (3.2)
 Cancer 2 (5.6) 3 (9.7)
 Psychiatric disease 1 (2.8) 2 (6.5)

Values are presented as mean ± standard deviation (range) or number (%).

BCVA = best-corrected visual acuity; logMAR = logarithm of the minimum angle of resolution.

* Independent t-test;

Chi-square test;

§ Fisher exact test;

Mann-Whitney U-test.

Table 4
Factors associated with high perceived stress in patients with glaucoma
Variable Univariable analysis Multivariable analysis

OR (95% CI) p-value OR (95% CI) p-value
Age (yr) 1.005 (0.967-1.044) 0.813 - -
Female sex 0.426 (0.157-1.155) 0.094 0.566 (0.189-1.692) 0.308
BCVA (better eye)* 8.454 (2.260-31.63) 0.026 4.707 (0.580-6.189) 0.072
Visual field mean deviation
 Better eye 1.178 (1.038-1.346) 0.011 1.159 (1.016-1.323) 0.028
 Worse eye 1.079 (1.008-1.155) 0.028 0.988 (0.890-1.095) 0.818
History of glaucoma surgery 3.750 (0.370-8.048) 0.264 - -
Medical benefit recipients 2.414 (0.208-7.983) 0.481 - -
Comorbidity 1.117 (0.414-3.014) 0.826 - -
No. of eye drops per day 1.095 (0.907-1.323) 0.345 - -

OR = odds ratio; CI = confidence interval; BVCA = best-corrected visual acuity.

* Per 0.1 logarithm of the minimum angle of resolution worse;

Per decibel worse.

Editorial Office
SKY 1004 Building #701
50-1 Jungnim-ro, Jung-gu, Seoul 04508, Korea
Tel: +82-2-583-6520    Fax: +82-2-583-6521    E-mail: kos@ophthalmology.org                

Copyright © 2022 by Korean Ophthalmological Society.

Developed in M2PI

Close layer
prev next