ORIGINAL STUDY
Evaluating the Quality of Life of Glaucoma Patients Using
the State-Trait Anxiety Inventory
Yasumasa Otori, MD, PhD,* Genichiro Takahashi, MD, PhD,†
Mitsuyoshi Urashima, MD, PhD,‡ Yasuaki Kuwayama, MD, PhD,§
and Quality of Life Improvement Committee
Purpose: To evaluate anxiety felt by glaucoma patients.
Patients and Methods: In total, 472 glaucoma patients responded to
a questionnaire on anxiety, subjective symptoms, and vision-related
quality of life (VR-QOL) associated with glaucoma. Anxiety was
evaluated using the State-Trait Anxiety Inventory (STAI), state
anxiety (STAI-State) subscale along with our novel questionnaire,
assessing visual function and subjective symptoms, specialized for
glaucoma. VR-QOL was evaluated using 5 subitems from the
25-item National Eye Institute Visual Function Questionnaire
(VFQ-25). Adherence to ophthalmic antiglaucoma agents was
confirmed. As indexes of visual function, corrected visual acuity
(measured by eye chart), mean deviation (MD) score (measured
with static perimetry), and 4 thresholds at the center of vision were
determined. Stages were classified according to the Aulhorn Clas-
sification. From the STAI-State scores, the prevalence of anxiety in
glaucoma patients was evaluated. We analyzed the correlation
between the STAI-State and VFQ-25, anxiety, subjective symptoms,
adherence, and visual function indexes.
Results: In total, 78% of glaucoma patients experienced at least an
intermediate level of anxiety. The STAI-State correlated sig-
nificantly with anxiety and subjective symptoms as measured by our
novel questionnaire, particularly for questions “current anxiety
about loss of vision” and “current anxiety in life” (r = 0.468 and
0.500; both P < 0.0001). However, STAI-State correlated weakly
with VFQ-25, and not at all with visual function indexes and
adherence.
Conclusions: Many glaucoma patients feel anxiety. The STAI-State
is correlated with the VR-QOL and anxiety in glaucoma patients,
making it useful for understanding the anxiety present in glaucoma
patients.
Key Words: adherence, glaucoma, quality of life, State-Trait Anxiety
Inventory, visual function
(J Glaucoma 2017;26:1025–1029)
Received for publication July 14, 2016; accepted July 31, 2017.
From the *Department of Ophthalmology, National Hospital
Organization Osaka National Hospital; §Fukushima Eye Clinic,
Osaka; †Department of Ophthalmology, Jikei University School of
Medicine, Katsushika Medical Center, Katsushika; and ‡Division
of Molecular Epidemiology, Jikei University School of Medicine,
Minato-ku, Tokyo, Japan.
Disclosure: M.U. received a fee for statistical analysis from Senju
Pharmaceutical Co. Ltd. The remaining authors declare no conflict
of interest.
Reprints: Yasumasa Otori, MD, PhD, Department of Ophthalmology,
National Hospital Organization Osaka National Hospital, 2-1-14
Hoenzaka, Chuo-ku, Osaka, 540-0006, Japan (e-mail: yotori@onh.go.jp).
Supplemental Digital Content is available for this article. Direct
URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journal’s Website,
www.glaucomajournal.com.
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/IJG.0000000000000761
J Glaucoma  Volume 26, Number 11, November 2017
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
G laucoma is an irreversible and progressive chronic disease
that leads to visual impairment. It is one of the major
diseases causing blindness. It is predicted that by 2020, 79.6
million people will be affected by glaucoma and 11 million of
those are expected to go blind.1 However, with appropriate
treatment, risk for blindness could be reduced,2 and vision-
related quality of life (VR-QOL) could be maintained
throughout the patient’s life. It has been reported that patients’
knowledge of the disease is a factor that affects adherence,3,4
and to improve adherence, it is important to discuss the risk
of blindness. Therefore, patients receive instruction on the
importance of improving adherence and/or maintaining good
adherence to, and the necessity for continuous treatment. It is
explained to patients that if glaucoma is left untreated or if eye
drops are not instilled according to the instructions, there is a
risk of blindness. However, this can cause excessive anxiety in
glaucoma patients.
It has been reported that 34% of glaucoma patients are
concerned about losing their sight; and thus, patients expe-
rience some degree of fear and/or anxiety.5 Many studies on
glaucoma have focused on the relationship of VR-QOL
associated with difficulties with daily work with visual
function;5–10 yet, few studies have focused on fear and
anxiety of blindness in glaucoma patients.5,11–14
Therefore, here, we used the Japanese version of the
State-Trait Anxiety Inventory (STAI),15 which is generally
used to measure anxiety, to quantify and determine the
prevalence of anxiety felt by Japanese glaucoma patients. In
addition, we examined its relationship with anxiety, treat-
ment adherence, subjective symptoms, VR-QOL, and visual
function indexes of glaucoma patients, and examined which
factors affect anxiety.
PATIENTS AND METHODS
Examination of the quality of life of glaucoma patients
by the Quality of Life Improvement Committee, using a
questionnaire, was implemented by multiple facilities in
Japan, including 18 medical institutions, between April 2007
and June 2008. The present study was performed with the
approval of the ethics committees and institutional review
boards of the participating institutions, and it strictly adhered
to the principles of the Declaration of Helsinki. Data analysis
was performed at the Division of Molecular Epidemiology,
Jikei University School of Medicine (Appendix, Supple-
mental Digital Content 1, http://links.lww.com/IJG/A132).
Patient background (excluding adherence and the
STAI), methods of determining visual function indexes, and
the method used for evaluation of subjective symptoms, the
anxiety perceived by glaucoma patients, and the VR-QOL,
have already been reported in detail in another paper,16 and
are only briefly mentioned here.
www.glaucomajournal.com | 1025
Otori et al J Glaucoma  Volume 26, Number 11, November 2017

Patients and Clinical Data Collection

TABLE 1. Unique Questions Relating to the Subjective Symptoms
Patients suffering from glaucoma or ocular hyper- and Anxieties of Glaucoma Patients
tension, who visited participating medical institutions, were
enrolled after obtaining written informed consent. Questions Answers and Scores*
We collected data on corrected visual acuity and field Subjective symptom
of vision for both eyes, along with patient backgrounds, Are you aware of the lack of the visual 1. Aware even when
from inquiries made by medical professionals or medical field (awareness of visual field defect) both eyes are open
records. Visual function indexes used for analysis were as 2. Aware when 1 eye is
follows: (1) corrected visual acuity; (2) Aulhorn classi- open
fication; (3) mean deviation (MD) values; and (4) maximum 3. Not aware
Does intraocular pressure bother you? 1. Not at all
and minimum values, as well as the sum of the minimum (concern about intraocular pressure)
and maximum values for the upper point, lower point, nasal 2. Rarely bothers me
point, temporal point, and all points; these were calculated 3. Occasionally bothers
based on 4 thresholds at the center of the field of vision me
(4 pericentral test points). Our previous paper showed that 4. Bothers me most of
minimum threshold values of the 4 pericentral test points on the time
the temporal side are useful for the assessment of 5. Always bothers me
VR-QOL.16 Adherence to the therapeutic agents that Do you feel that your visual field has 1. Not at all
patients were using for glaucoma was ranked in 3 levels: been disturbed? (awareness of
progression of visual field disorders)
good (80% to 100%), somewhat poor (51% to 79%), and 2. Rarely feel
poor ( ≤ 50%). Adherence was evaluated by inquiry of 3. Occasionally feel
individual patients by medical staff. Subsequently, patients 4. Feel most of the time
were requested to complete the questionnaire (Fig. 1). 5. Always feel
Anxiety
Evaluation of Anxiety and VR-QOL When you were originally diagnosed 1. Not at all
The questionnaire used in this study was prepared by with glaucoma, did you feel that you
the QOL Improvement Committee, and was distributed to might lose your vision? (anxiety about
the participants. The questionnaire consisted of 33 ques- loss of vision at the initial visit)
2. Hardly felt
tions, including 6 questions selected from the state anxiety 3. Felt
domain of the Japanese STAI (STAI-State), 10 questions on 4. Strongly felt
patient background, 7 questions on subjective symptoms 5. Extremely strongly
and anxiety felt by glaucoma patients, which were uniquely felt
prepared by the QOL Improvement Committee (Table 1), Do you now feel the anxiety of losing 1. Not at all
and 10 questions on visual function selected from the vision? (anxiety about loss of vision,
Japanese 25-item National Eye Institute Visual Function current)
Questionnaire (NEI VFQ-25) for evaluating VR-QOL.17 2. Rarely feel
Among questions on subjective symptoms and anxiety 3. Occasionally feel
4. Feel most of the time
felt by glaucoma patients, only the question—“awareness of 5. Always feel
visual field defect”—is scored high when a patient is When you were originally diagnosed 1. Not at all
unaware. Questions on visual function selected from the with glaucoma, did you feel anxiety
Japanese NEI VFQ-25 are “general vision,” “near vision,” that you might experience
“distance vision,” “peripheral vision,” and “driving.” inconvenience in work and daily life at
The Japanese STAI was created based on the STAI home? (anxiety in life at the initial
Form Y,18 and consists of 20 questions on state anxiety visit)
(STAI-State) and 20 questions on trait anxiety (STAI-Trait), 2. Hardly felt
3. Felt
4. Strongly felt
5. Extremely strongly
felt
Do you now feel anxiety that you may 1. Not at all
experience inconvenience in work and
daily life at home? (anxiety in life,
current)
2. Rarely feel
3. Occasionally feel
4. Feel most of the
*Select 1 answer only. The numbers in front of the selections of answers
indicate scores.

totaling 40 questions. State anxiety represents the present

FIGURE 1. Flowchart showing the number of patients who were
enrolled and analyzed in this study. We excluded 12 glaucoma
patients with other associated severe eye diseases.
and transient state about a phenomenon that incites anxiety,
whereas trait anxiety represents the typical disposition of the
person; that is, how anxious a person regularly feels. For
each question, 1 answer is selected from among 4 levels,
which is scored between 1 and 4, and the total score is then

1026 | www.glaucomajournal.com Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
J Glaucoma  Volume 26, Number 11, November 2017 Evaluating the Glaucoma Patient’s Anxiety Using the STAI

used. For each scale, the total score ranged between 20 and
80, with a higher score indicating stronger anxiety. A score TABLE 2. Patients’ Characteristics
of 55 or higher indicates a high level of anxiety, ≥ 45 to <55 Total Patients (n = 472)
indicates an intermediate level of anxiety, and <45 indicates Men/women (n) 217/255
a low level of anxiety.19 Age (mean ± SD) (y) 62.4 ± 13.1
However, responding to all questions can be cumber- Period suffering from glaucoma 7.0 ± 6.6
some for subjects. Therefore, Marteau and Bekker20 pre- (mean ± SD) (y)
pared a short version based on the STAI-State. The short Corrected visual acuity (mean ± SD)
version consists of 3 questions each for anxiety-present items (logMAR)
and anxiety-absent items, and has been reported to correlate Better eye/worse eye −0.04 ± 0.13/0.07 ± 0.31
with the results of the full-length STAI-State. Therefore, in Mean deviation (mean ± SD) (dB)
Better eye/worse eye −6.3 ± 8.5/−11.3 ± 8.9
the present study, we selected 3 anxiety-present items— Type of glaucoma (right eye/left eye) (n)
secure, misfortunes, and worried—and 3 anxiety-absent POAG 405/405
items—regretful, comfortable, and joyful—with a high ACG 25/25
coefficient of internal consistency (item-remainder correla- Mixed glaucoma 4/3
tions: 0.4 or higher)19 from the STAI-State, and used this Secondary glaucoma 29/33
short-version STAI-State in the study (total score range, 6 Developmental glaucoma 4/4
to 24). The total score obtained was proportionally calcu- Others 5/2
lated to be equivalent to 20 questions of the full-length NEI VFQ-25 subscale score (mean ± SD)
STAI-State, and scores above a cut-off of 45 points— General vision 71.01 ± 15.04
Near vision 73.70 ± 18.69
equivalent to intermediate anxiety—were defined as clin- Distance vision 76.90 ± 15.95
ically significant for evaluating the prevalence of anxiety. Peripheral vision 72.94 ± 21.83
Driving (daylight familiar 74.90 ± 24.50
Statistical Analyses places/driving at night) (81.4 ± 26.9/69.7 ± 38.0)
Using Spearman rank correlation coefficient, we ana-
ACG indicates angle-closure glaucoma; logMAR, logarithm of minimum
lyzed the relationship of the short-version STAI-State with: angle of resolution; NEI VFQ-25, 25-item National Eye Institute Visual
(1) subjective symptoms and anxiety obtained from our own Function Questionnaire; POAG, primary open angle glaucoma.
questions; (2) 5 subitems from the VFQ-25; (3) adherence;
and (4) visual function indexes. “Driving,” which is a sub-
item of NEI VFQ-25, was divided into “daytime driving” On the basis of the STAI-State score after the proportional
and “nighttime driving” to evaluate the correlation. Baseline calculation, 45 cases (10.0%), 306 cases (68.0%), and 99 cases
patient background, scores for items, and test results are (22.0%) were classified as having a high level of anxiety,
reported as mean ± SD. intermediate anxiety, and low anxiety. Therefore, the prev-
Since the survey included a wide range of items, stat- alence of significant anxiety among glaucoma patients was
istical significance was indicated by P < 0.0001. A correla- 78.0% (351/450).
tion coefficient of ≥ 0.4 or ≤ −0.4 was deemed a strong
correlation. STATA version 9.0 (STATA Corp LP, College Correlation With STAI
Station, TX) was used for all statistical analyses. There was a correlation between the short-version
STAI-State and the questions on subjective symptoms and
RESULTS anxiety in glaucoma patients that we had prepared in all
items (Table 3). Specifically, questions—“Do you feel the
We obtained patient background and completed
anxiety of losing vision even now?” and “Do you now feel
questionnaires from 472 subjects (217 males and 255
anxiety that you may experience inconvenience in work and
females) (Fig. 1). The mean age of participants was
daily life at home?”—were strongly correlated (r > 0.4).
62.4 ± 13.1 years (range, 29 to 85 y) and the mean duration
STAI-State and subitems of VFQ-25—“distance
of glaucoma was 7.0 ± 6.6 years (range, 1.0 to 31.4 y).
vision,” “peripheral vision,” and “driving” presented
Table 2 shows the visual function indexes and scores of
the 5 subitems from VFQ-25. Stages of the upper and lower
half of the field of vision, classified according to the Aulhorn TABLE 3. Correlation Coefficient Between Short-Version STAI-S
classification, ranged between stages 0 and VI. The thresh- and Questions on Subjective Symptoms and Anxiety in Glaucoma
old of the central 4 points were 0 to 36 dB for the upper Patients
point, 0 to 40 dB for the lower point, 0 to 40 dB for the nasal Short-Version
point, and 0 to 39 dB for the temporal point. The means STAI
for the sum of the maximum and minimum values were
44.0 ± 18.2 dB for the upper point, 48.1 ± 18.6 dB for the Awareness of visual field defect −0.209
lower point, 44.8 ± 17.9 dB for the nasal point, and Concern about intraocular pressure 0.278
Awareness of progression of visual field 0.325
47.0 ± 19.2 dB for the temporal point. disorders
In the 452 cases in which it was possible to determine Anxiety about loss of vision at the initial visit 0.269
adherence, 94.0% of the patients were determined as show- Anxiety about loss of vision, current 0.468
ing good adherence, whereas 5.8% showed somewhat poor Anxiety in life at the initial visit 0.308
and 0.2% showed poor adherence. Anxiety in life, current 0.500
In total, 450 subjects completed the short-version STAI-
In cases where P < 0.0001, the values show correlation coefficients.
State. The mean score for the 6 questions (full score, 24) was Bold type represents correlation coefficients (r) > 0.4.
14.6 ± 1.5. The mean score was 48.6 ± 5.1 after proportional STAI indicates State-Trait Anxiety Inventory.
calculation to the 20 questions of the full-length STAI-State.

Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved. www.glaucomajournal.com | 1027
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Otori et al
TABLE 4. Correlation Coefficient Between Short-Version STAI-S
and the 5 Subscales of the VFQ-25
Short-version STAI
General vision NS
Near vision NS
Distance vision −0.259
Peripheral vision −0.233
Driving −0.307
Daylight familiar places −0.368
Driving at night −0.254
In cases where P < 0.0001, the values show correlation coefficients.
NS indicates not significant; STAI, State-Trait Anxiety Inventory; VFQ-
25, 25-item National Eye Institute Visual Function Questionnaire.
negative correlation (Table 4). However, there was no
strong correlation. There was no correlation between the
STAI-State and “general vision” or “near vision.”
There was no correlation between the STAI-State and
treatment adherence, or between the STAI-State and any of
the visual function indexes.
DISCUSSION
The present report quantified the anxiety felt by glau-
coma patients using the STAI, including the same subjects
as in the report by Takahashi et al,16 and examined the
relationship of anxiety with VR-QOL and visual function
indexes.
The STAI is widely used to survey anxiety in cancer
patients, pregnant women, and perioperative patients.21–24
STAI-State, which is a subscale of the STAI, evaluates the
anxiety that is being felt at the present time, which is a
transient state reaction to a situation that causes anxiety,
and is known to change every moment. The level of state
anxiety increases if a situation is perceived as a threat, but is
relatively low in a situation with little risk.
In this study, the short-version STAI-State scores that
had been obtained were proportionally calculated to derive
the full-length STAI-State score. The mean of this score was
48.6 ± 5.1, and the previously defined prevalence of sig-
nificant anxiety was 78.0%, indicating that many glaucoma
patients experience an intermediate level of anxiety. In the
present study, the cut-off STAI-State score for determining
clinically significant anxiety was defined as 45 points.
According to a previous report on the STAI subscale cut-off
values,23 clinically significant anxiety could be detected with
a cut-off value of 39 to 40. However, in seniors, it was
proposed to be 54 to 55. In a report by Agorastos et al,14
who used the STAI to detect anxiety in glaucoma patients,
the subscale cut-off value was set at > 44. Therefore, the
cut-off value of 45 used in the present test is considered to be
valid. According to Agorastos et al,14 the STAI-State score
in glaucoma patients aged 50 years or older ranged from
32.0 to 37.5, which is lower than that in the present study.
One reason for this could be that the mean age of those
subjects was 70.8 ± 8.4 years, which is higher than that of
participants in the present study (62.4 ± 13.1 y). It has been
reported that anxiety and age are correlated, with a younger
age associated with stronger anxiety.13 The prevalence of
anxiety in Japanese glaucoma patients was high, at 78.0%.
The cause of this difference is unclear, but differences in age
and race may have had an effect.
The STAI-State showed a strong correlation with 2
questions on subjective symptoms and anxiety in glaucoma
1028 | www.glaucomajournal.com Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
J Glaucoma  Volume 26, Number 11, November 2017
patients that were prepared in this study: “do you now feel
the anxiety of losing vision?” and “do you now feel anxiety
that you may experience inconvenience in work and daily
life at home?” (r = 0.468 and 0.500, respectively). It is pos-
sible that our question about the anxiety of losing vision
itself could induce anxiety. However, questions on sub-
jective symptoms that are specific to glaucoma patients were
more strongly correlated with VR-QOL than with the STAI-
State.16 In addition, the STAI-State was not correlated with
the VR-QOL to a significant degree, and there was no
correlation between the STAI-State and visual function
indexes. Therefore, we should manage glaucoma with con-
sideration of both the mental state of patients and functional
and structural changes in glaucoma.
The present examination was cross-sectional and did
not include an age-matched and sex-matched control group;
thus, future studies should investigate how anxiety experi-
enced by glaucoma patients changes with progression of
visual impairment. However, importantly, we show here
that the anxiety of glaucoma patients could be evaluated
using a questionnaire consisting of 6 simple questions. In
contrast, using the STAI-State, the details of the anxiety
could not be understood. Odberg et al11 classified negative
emotions felt by glaucoma patients into anxiety, fear of
blindness, and depression. When using the STAI in a routine
examination, physicians should attempt to gain further
detailed understanding of the patient based on the results of
this assessment.
Treatment adherence was considered good at 90% or
higher in this study, and there was no correlation between
the STAI and treatment adherence. Adherence was eval-
uated either by enquiries by medical professionals or from
medical records. We asked individual patients about their
adherence to the prescribed therapy. However, this inter-
view method is known to tend to underreport the frequency
of omitted doses.25 Therefore, it is possible that adherence
was quite high in this study. Hence, its accuracy is limited,
and this is a limitation of this study. However, as Holló
et al26 also reported that anxiety, evaluated using the STAI,
and treatment adherence, evaluated using ophthalmic
measurement equipment, did not correlate, it is assumed
that there is no relationship between anxiety and treatment
adherence. Therefore, in a routine examination, it is not
appropriate to emphasize possible loss of sight, and thereby
cause excessive anxiety, to improve adherence.
The present examination showed that many glaucoma
patients experience anxiety. In addition, the current anxiety
about losing sight and anxiety about experiencing incon-
venience in life was shown to be reflected well in the short-
version STAI-State. The STAI-State is an effective tool for
quantifying anxiety in glaucoma patients, and monitoring
the anxiety of glaucoma patients using the STAI-State is
believed to be important in maintaining their QOL.
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