Background : Eye disorders extol great impact on the quality of life and mental health of individuals, thus constitute a public health concern. This study aimed to evaluate the prevalence and sociodemographic characteristics of psychological problems among patients with eye disorders in a major eye clinic in southwest Nigeria. Materials and Methods : It was a cross-sectional survey. Consecutive patients attending the clinic over a period of 6 weeks were administered questionnaire with sections on demographic and clinical characteristics, General Health Questionnaire and Hospital Anxiety and Depression Scale to assess psychological morbidity, anxiety, and depressive disorders. Results : One hundred and forty-seven respondents consisting of 51.7% female took part in the study. Glaucoma (28.6%) was the most frequent diagnosis. About a fifth (19.7%) of the respondents had psychological morbidity, while 15 and 14.3% of the respondents screened positive for anxiety disorder and depression respectively. More than half of the respondents (54.4%) had poor visual acuity. There was no statistical difference between the respondents who were visually impaired compared with those that were not as far as psychological morbidity (P = 0.93), anxiety (P = 0.99), and depression (P = 0.22) are concern. Respondents with comorbid conditions were significantly more likely to have psychological morbidity (P = 0.05) and anxiety disorders (P = 0.02) compared with those without comorbidity. Conclusion : There is high prevalence of psychological disorders among ophthalmic patients with or without visual impairment. Thus, assessment for psychological distress and other emotional disorders such as anxiety and depression among patients presenting with eye disorders is very important.
Keywords: Anxiety and depression, eye disorders, psychological morbidity
Visual impairment resulting from various kinds of eye disorders creates major emotional and psychological distress far beyond difficulties from other sensory impairment for most individuals.  The awareness of the gradual decline in visual acuity and risk of blindness usually results in significant adjustment difficulties in virtually the totality of the individual’s life.
Visual problems extol great impact on the quality of life, self-dignity, and mental health of individuals.  Depression and anxiety disorders have been reported to be of high prevalence among patients with various eye disorders. ,,, Increasingly, these psychological parameters have gained almost equal importance in therapeutic management and outcome at improving visual acuity. 
The complex relationship of various eye disorders with depression and anxiety varies with different eye disorders. ,,, These disorders have a negative prognostic factor and cause much longer hospital days.  Eye disorders primarily cause deficits in the individual’s occupational, social, and general functioning which can fuel mood problems and the relationship can also be bidirectional.  Importantly, eye disorders constitute a public health concern due to the high numbers of individuals suffering from these disorders on a global scale and its association with psychological morbidity. Anxiety and depression are major causes of disability independent of vision loss. , Thus, comorbidity of eye disorders with depression or anxiety disorders is more distressing to cope with than the primary visual problem.
In Nigeria, eye disorders constitute a sizeable proportion of consultations in tertiary health institutions and primary health care facilities.  However, many of these individuals rarely complain of psychological or emotional disorders associated with their visual problems to the attending physicians. This situation has led to an increasing number of patients who are ill-satisfied with ophthalmic treatment and bear their burden in silence.
Very few studies in Nigeria have highlighted the prevalence of depression and mood disorders across various types of eye disorders. This has limited the data available to eye physicians to predict and detect psychological problems among patients with various eye disorders.
The aim of this study is to evaluate the prevalence and sociodemographic characteristics of psychological problems among patients with eye disorders in a major eye clinic in southwest Nigeria.
The survey was done at the Eye Clinic of the Olabisi Onabanjo University Teaching Hospital, Sagamu. The eye clinic is under the supervision of the consultant ophthalmologists assisted by resident doctors. The clinic acts as both a major referral center and primary care unit for patients within the southwest region of Nigeria.
It was a cross-sectional survey. Consecutive patients attending the clinic who signed informed consent were recruited over a period of 6 weeks.
A purposely designed sociodemographic questionnaire was designed to capture relevant sociodemographic details such as age, sex, marital status, tribe, religion, and employment status.
A thorough history of complaints with eye examination was initially carried out on all the respondents by the consultant ophthalmologists. Diagnosis was made in accordance with the international classification of diseases 10 version for 2010. Visual acuity assessment was done using Snellen’s chart and “E” chart in illiterate subjects. Visual impairment was defined as visual acuity of 6/9 and below.
General Health Questionnaire
The General Health Questionnaire (GHQ-12) was used to assess psychological morbidity among respondent.  It has been validated for use in this environment.  The GHQ -12 is quick to administer and easy to use.
Hospital Anxiety and Depression Scale
The Hospital Anxiety and Depression Scale (HADS) developed by Zigmond and Snaith in 1983,  is a 14-item instrument especially designed for use among nonpsychiatric patients. It has been widely used for detecting anxiety and depression in various settings in Nigeria.  Each of the scale has equal number of items of measure.
The data obtained were analyzed using the Statistical Package for Social Sciences software. Results were presented in simple frequency tabulations. Chi-square was used to determine strength of relationships in comparing categorized data. A P-value of 0.05 or less was considered as statistically significant.
Out of 170 individuals who visited the clinic during the period of the study, 147 agreed to take part in the study by signing the informed consent form [Table 1]. The ages of respondents ranged between 19 and 91 years, the mean age was 53 ± 18 years. Females were slightly more than males (51.7%, n =76). More than two-thirds were married (68%, n = 100) and a minority were unemployed (12.3%, n = 18).
Clinical characteristics of respondents
The most frequent diagnoses were glaucoma (n = 42, 28.6%), disorder of ocular muscles, accommodation, and refraction (e.g., presbyopia) (n = 32, 21.7%) and disorder of lens (e.g.,cataract) (n = 31, 21.1%) [Table 2]. The mean duration of illness was 5.03 ± 6.93 years. More than a quarter had comorbidities with the presenting eye disease (n = 42, 28.6%). The mean score for GHQ was 1.50 ± 2.13. The range of scores was from 0 to 11. On the anxiety and depression scales of the HADS, the mean score on the anxiety scale was 4.03 ± 3.32, while on the depressive scale was 3.92 ± 3.3. Using a cut-off score of ≥3 for psychological morbidity, about a fifth (n = 29, 19.7%) of the respondents had psychological morbidity. On the anxiety and depression scale using a cut-off of ≥8 22 respondents (15%) screened positive for anxiety disorder, while 21 (14.3%) screened positive for depression.
More than half of the respondents (54.4%, n = 80) had poor visual acuity as defined by a visual acuity of 6/9 and below in either one or both eyes. Among those with poor visual acuity, half of them had impairment in both eyes (n = 40, 50%), while there was equal number of respondents with single impairment either in the right or the left eye. Among those that were visually impaired, 16 (20%) screened positive for psychological morbidity. On the HADS, 12 (15%) had anxiety, while 14 (17.5%) had depression.
Visual impairment with comorbidity, psychological morbidity, anxiety, and depression
As shown in [Table 3], visual acuity was tabulated with scores from the GHQ and HADS. There was no statistical significance between the respondents who were visually impaired compared with those that were not on the psychological morbidity scale (P = 0.93). Similarly, on the HADS, there was no statistical significance between respondents who were visually impaired compared with those that were not visually impaired on the anxiety scale (P = 0.99) and on the depressive scale (P = 0.22).
Respondents with comorbid conditions were significantly more likely to have psychological morbidity on the GHQ than those without comorbidity (35.7% vs 17.1%, P = 0.05). Similarly, those with comorbidity were also more likely to have anxiety disorders compared with those without comorbidity (35.7% vs 7.6%, P = 0.02). However, although a higher proportion of the respondents with comorbid eye conditions screened positive for depression (19.0%) than those without comorbid conditions (14.3%), the difference was not significant (P = 0.65).
The study highlights the prevalence of psychological distress and disorders among patients presenting with eye-related disorders at a major ophthalmological clinic in southwest Nigeria. It was observed that females were slightly more than males in the gender distribution. This is similar to the gender distribution in the same center in patients with diabetes mellitus.  This may be a reflection of attitude to health care across gender. More than half of the respondents presented with visual impairment, the high percentage may be due to the late presentation of eye disorders which is quite common among patients with eye disorders in Nigeria. ,, Findings from our study ranked glaucoma as the most common diagnosis, with disorders of ocular muscles, accommodation, and refraction; and disorders of lens in successive order. These diseases impact negatively on visual acuity and has been often reported as some of the leading causes of blindness/impairment in Africa. ,,
About a fifth (19.7%) of respondents with eye disorders in our study were found to be at risk for psychological morbidity. Patients with visual problems have been reported to have high prevalence of psychological morbidity due to difficulties fostered by the impairment. ,,, Visual problems constitute major psychological burden on individuals who suffer from eye pathologies similar to those with chronic illnesses. , The high prevalence among individuals with eye disorders illustrates the magnitude of the psychological distress that most eye disorders have on sufferers. The prevalence of psychological morbidity, anxiety, and depression in our study was more than that reported in similar setting in a cohort of diabetic patients where similar instruments were used.  S imilar to other chronic illnesses, eye disorders create additional psychological turmoil which may potentially give rise to undue fear, tension, limits social interaction, fosters isolation, and breeds low self-esteem. ,,
Conversely also, eye disorders may impact negatively on preexisting psychological distress.  A study by Gureje et al. in this environment reported psychological morbidity, anxiety, and depression in the general population to be 5.8%, 4.1%, and 4.1%, respectively. The prevalence of psychological morbidity, anxiety, and depression among ophthalmic patients in our findings (19.7%, 15%, and 14.3%, respectively) was far higher than that reported in the general population. Visual problems create major emotional and psychological distress, and extol great impact on the quality of life and self-dignity of the sufferers. ,
There was no significant difference among those with visual impairment compared with those without as far as psychological morbidity/ disorder is concern. This observation in our study may be due to the fact that any ocular disorder could provoke threat of eventual visual loss in the sufferer. However, Abateneh et al.  found a significant difference between patients with visual impairment and those without in Ethiopia. Invariably from our findings eye pathologies resulting in visual impairment or not exert considerable psychological burden on individuals.
Anxiety and depression have often been reported as a major comorbid psychological condition with eye disorders. The rate tends to increase with associated visual impairment.  Our finding of 15% prevalence of anxiety disorder does not differ from findings of surveys of anxiety that has been reported in different settings. , Apart from the difficulty affecting vision, other factors fueling anxiety may include issues such as pain and cosmetic concerns.
Our study mirrors previous reports from studies which reported association between eye-related problems and depression. ,,,, The deficits in social activity and disability create major emotional issues with resultant depressive symptoms. Although there was a higher rate of psychological morbidity and depression in those with visual impairment compared to those with no visual impairment, the difference was not significant. Our findings may suggest that visual impairment does not confer significant differences in the prevalence of psychological distress among individuals with eye disorders.
However, patients having comorbid medical conditions had significantly higher rates of psychological morbidity and anxiety. They also reported higher rate of depression though the difference was not significant. Comorbid conditions confer additional psychological burden on patients with eye disorders and could be a significant factor in the high prevalence of psychological morbidity, anxiety, and depression among individuals with visual problems.  These findings hold important implication for eye physicians in managing patients with comorbid eye disorders. Detection of psychological morbidity and keying it in the management of these patients would be helpful in the treatment of the comorbid eye disorder.
The high prevalence of psychological disorders in our study shows the importance of assessing for psychological distress and other emotional disorders, such as anxiety and depression among patients presenting with eye disorders with or without visual impairment. Most often patients with eye disorders do not lay complaints of emotional and psychological distress before eye physicians in Nigeria. Enquiries about psychological difficulties should be an important part of assessment among individuals with eye disorders. It should be factored into the therapeutic approaches in the management of various eye disorders regardless of association with visual impairment or not. Comorbid medical conditions are particularly noteworthy situations for higher risk of psychological difficulties. Routine screening of individuals with comorbid eye disorders for psychological morbidity should be done regardless of presence or absence of associated visual impairment.
The nature of our sample size and cross-sectional nature of our study limit the generalization of our findings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
OOO conceived the study, and participated in its design, acquisition, analysis, and interpretation of data, and in the drafting of the manuscript.
BOT participated in its coordination and acquisition of data.
ATO participated in the design of the study, statistical analysis of the data and the draft of the manuscript.
OOO coordinated and assisted in the final drafting of the manuscript.
AF participated in the design of the study and the final drafting of the manuscript.
All authors read and approved the final manuscript.
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]