• Emotional

• Physical

• Social

• Workplace

Maslow’s theory (as summarised diagrammatically in Figure 1) suggests basic needs must be satisfied before higher level physiological needs if we are to achieve self-fulfilment and ‘happiness’(4).

Figure 1: Maslow’s theory of need

Eye health and mental health

Opportunities for identifying issues related to wellbeing and for discussion of options to address these at various stages of the eye examination are outlined in Figure 2 and are summarised as the following handy six clinical pearls:

Figure 2: Potential wellbeing touch points during eye examinations(5)

1. Keep an eye out!

Observe their behaviours, attitude, the way they talk and move. Clues may include lack of eye contact, head down position, nervousness, low energy levels/interest, mood changes, tiredness, withdrawn tendencies, eye twitching in those with stress or excessive sweating.

Consider your own impact and take a calm reassuring approach, regularly pausing to clarify their understanding and provide a chance to ask questions.

Researchers have found that a single, quick glance of a person’s face (just 33 to 100ms) is sufficient for the viewer to form an initial impression of that person(6). This is worth remembering as patients will quickly form an opinion of you as their eye care professional (ECP), perhaps picking up on your mood, making a judgement of your confidence, professionalism or authority. To make a positive impression from the start, always greet the patient by their name and welcome them into your consulting room with a smile. Staff and practice appearance all contribute to this initial impression; under current conditions, this might reinforce trust by obvious adherence to current guidance on cleanliness and sterility, while still maintaining friendliness and approachability.

2. All inclusive, inquisitive approach

Thankfully the stigma around talking about mental health issues is vanishing. Show an interest in your patient as a person as well as their eye health. Sometimes asking open questions such as “how are you today?” or ‘how’s your day been?”, is all that is needed to spark these conversations, followed by good active listening skills. Acknowledging their responses with phrases such as “Thank you for sharing…” is a good way to encourage them to elaborate and reveal additional useful information.

Mental health conditions do not discriminate, so avoid making presumptions. Even top athletes and children may suffer from mental health and eye issues. A study found the mental health symptoms and disorders in current elite athletes ranged from 19% to 34% distress for anxiety/depression(7).

On a positive note, at the time the Tokyo Olympics in 2020 significantly raised the awareness of athletes and mental health. In fact, it was reported that on the day US gymnast Simone Biles’ decision to withdraw from the Olympics was announced there was the highest peak in mental health related Google searches and the news generated more social media interactions than Prince Harry and Meghan’s controversial interview with Oprah Winfrey(8)!

Ocular signs in children can include visual disturbances, headaches with or without visual disturbance and/or new ocular tics (short infrequent bursts of involuntary uncontrolled eye movements), of which an underlying neurological cause can be ruled out by the absence of other typical indicators of neurological disease. These cases are likely to be induced by a heightened emotional state, for example stress or anxiety and potential triggers may include being bullied at school(9).

For children with cataract the incidence of mental health issues is nearly double that of children without cataract(10). The Charity YoungMinds recently warned the number of under-18s being referred to the NHS for mental health support rose to 1.2 million in 2022 and WHO reported around one in seven of the world’s adolescents have a mental disorder(2). The Daily Mail Online ran recently with the eye-catching headline “Record 1 million antidepressant prescriptions dished out to teens” reflecting the current situation in England(11). To complete the bleak picture, at least one in six adults in the UK was prescribed antidepressants in 2021/22.

In general, ocular symptoms appear more correlated to some mental health issues than clinical signs(12). Gathering information in advance of the appointment, using triaging questions or questionnaires, may be a useful complement to history taking and help overcome any concerns of increasing consultation time.

3. Risky Tendencies!

Identifying risk factors such as lifestyle or routine changes are important, for example a shift to more reclusive activities to avoid social interactions or frustrations with performing activities/hobbies. The patient may be spending significant periods alone on digital devices and preferring less healthy lifestyle choices. Viewing screens for six hours or more has been linked to depression and dry eye(13). Sleep issues are also more common and have been associated with symptomatic eye conditions.

Importantly, most emotional issues influence physical health issues. Such systemic health issues (heart problems, stroke, diabetes, high blood pressure, raised cholesterol to name a few) can lead to eye problems. This shows the importance of gathering a detailed medical history.

Symptomatic co-morbidities – especially painful conditions or those that have an impact on quality of life and functioning – also have higher associations.

Medications taken for mental health issues have been associated with potential ocular side effects (Table 1)(14). Interestingly, although antidepressants can help treat the symptoms of depression, they do not always address the cause, although the benefits for example on uplifting mood and behaviour are likely to justify usage over risks of ocular manifestations such as dry eye. Recent NICE guidelines recommend that, for mild depression, behavioural therapy or group exercise should be the first line treatments instead of medication, unless this is the individual’s preference. The guidance also promotes the value of other techniques such as mindfulness and meditation(15).

Table 1: Ocular adverse effects of some medications used for mental health(14)

4. Bright eyed and bushy tailed

Mental health issues that have been associated with common ocular pathology – in a systemic review – included dry
eye (29%), glaucoma (25%), AMD (24%) and cataract (23%). They also may have impacts on physical health (for example vascular conditions, diabetes, stroke)(1). Another systemic and meta-analysis review, in 2021, found a depression prevalence of 40% in dry eye disease patients and 30% for anxiety compared to controls(16).

In the young, those with congenital eye conditions are more at risk than those without and at the other extreme more elderly individuals are considered more vulnerable to having both mental health and eye pathology.

For at-risk patients, consider conducting a detailed eye health assessment, in particular a full ocular surface examination, pupil assessments, closer inspection for any potential vascular changes and glaucoma screening. It is important to identify narrow angles. With stress and anxiety there can be spikes in intraocular pressure (IOP) and it has been proposed that long term this can increase the risk of optic nerve damage. Researchers have suggested that “Anxiety increases the risk of glaucoma progression and is associated with the IOP profile and disc haemorrhages”(17).

There is also an association between severity of eye disease and mental health conditions.

5. Clearly seeing the world to its full potential

There is a clear association between visual impairment and mental health conditions. Loss of vision has been linked to loneliness, social isolation, an impact on ability to develop personal relationships and heightened feelings of worry, anxiety and fear.

Those with mental health issues may complain of visual symptoms such as blurry vision, headaches or eye strain, and subjective refraction may be more variable. Reasonable adjustments during eye testing may include using larger steps during refraction or more dependence on objective results. Measurements of reduced levels of accommodation and
near vision difficulties may signify a need for a higher reading add than would usually be expected(14). Maximising visual potential by providing refractive error correction, offering a range of eyewear solutions and, where appropriate, advice on low vision service provisions is advisable.

Sharing is caring

Some individuals may be embarrassed or self-conscious about their mental health state. However, with careful and sensible interaction, a patient might be encouraged into being more open about their state of mind. Their lack of awareness of any potential link between mental health and eye health may mean they initially do not see the relevance of discussing these aspects.