Screening and analysis of influencing factors for comorbidity of chronic glaucoma with depression and anxiety

Abstract

BACKGROUND

It has been reported that the prevalence of glaucoma among the global population aged 40-80 years is 3.50%. The majority of patients with chronic glaucoma experience psychological stress in the form of depression and anxiety, which may contribute to disease progression via psychoneuroendocrine mechanisms. However, current clinical screening for these comorbidities remains incomplete.

AIM

To analyse the specific prevalence of depression and anxiety in patients with chronic glaucoma and to investigate the potential associated factors.

METHODS

A total of 220 patients with chronic glaucoma who received treatment at our hospital between January 2024 and October 2025 were included in the study. Their levels of depression and anxiety were assessed using the Generalised Anxiety Disorder Scale and the Patient Health Questionnaire Depression Scale questionnaire. According to the screening results, we divided the 220 patients into a comorbid depression and anxiety group (n = 61) and a non-comorbid group (n = 159). Sociodemographic data, ophthalmic clinical characteristics, and medication history were collected. Univariate and multivariate logistic regression analyses were performed to identify independent influencing factors for comorbid depression and anxiety and to construct a joint prediction model.

RESULTS

Among the 220 chronic glaucoma patients, the detection rate of comorbid depression and anxiety was 27.73%. The proportions of female patients, patients aged ≥ 40 years, those living in urban environments, those with an education level below high school, those with a monthly family income ≤ 3000 yuan, those with a disease duration ≥ 10 years, and those with moderate-to-advanced visual field defects were significantly higher in the comorbid group than in the non-comorbid group, while best-corrected visual acuity was lower in the comorbid group. Univariate logistic regression analysis showed that age, education level, monthly family income, disease duration, stage of visual field defect, and degree of visual impairment were associated with comorbid depression and anxiety. Multivariate logistic regression analysis indicated that longer disease duration, more severe visual field defects, and lower monthly family income were independent risk factors for comorbid depression and anxiety in chronic glaucoma patients. The Hosmer-Lemeshow test showed good model calibration.

CONCLUSION

Comorbid depression and anxiety are relatively common in patients with chronic glaucoma. Longer disease duration, more severe visual field defects, and poorer economic status are independent risk factors. Clinical attention should be paid to the psychological screening and comprehensive intervention for such patients.

Key Words: Glaucoma; Comorbid depression and anxiety; Screening; Influencing factors; Predictive model; Visual field defect

Core Tip: This analysis of 220 chronic glaucoma patients identified a 27.73% comorbidity rate of depression and anxiety. Longer disease duration, more severe visual field defects, and lower monthly family income were independent risk factors. It is therefore necessary to carry out psychological assessments and implement multi-dimensional interventions for this patient group.

INTRODUCTION

Glaucoma is primarily caused by the loss of retinal ganglion cells and degeneration of the retinal nerve fibre layer[1], and is often characterised by specific visual field defects. Statistics indicate that approximately 3.50% of people aged between 40 and 80 worldwide are affected by the condition[2]; on the one hand, the disease erodes patients’ visual function, leading to structural changes such as optic nerve atrophy and an increased cup-to-disc ratio; on the other hand, it can even result in complete loss of vision or blindness. Furthermore, patients must undergo continuous treatment from the moment of diagnosis[1], which places a heavy psychological burden on them. Ajith et al[3] and their colleagues found that the prevalence of depression and anxiety was significantly higher in the glaucoma group than in the control group. Dayal et al[4] also found a significant association between anxiety and depression scores and the severity of glaucoma, suggesting that negative emotions exacerbate the condition to some extent. Ren and Li[5] found that sleep disturbances caused by emotional problems may accelerate disease progression by inducing fluctuations in visual field and autonomic nervous system dysfunction. Furthermore, psychological stress associated with fluctuations in intraocular pressure also contributes to the progression of glaucoma. Therefore, using depression and anxiety as screening factors for glaucoma patients, in conjunction with psychological counselling, holds significant clinical value for disease management and patient prognosis. Although there are currently numerous reports on anxiety and depression in glaucoma, systematic screening and factor analysis of these conditions remain relatively rare. Consequently, this study aims to investigate the current prevalence of comorbid depression and anxiety among glaucoma patients and to further analyse the factors influencing these conditions, thereby providing a reference for clinical intervention.

MATERIALS AND METHODS

General information

A total of 1246 patients with chronic glaucoma attending the ophthalmology outpatient clinic at our hospital between January 2024 and October 2025 were selected. A total of 220 patients meeting the inclusion criteria were enrolled using a consecutive sampling method.

Inclusion criteria: (1) All patients had a confirmed diagnosis of primary glaucoma[6] and presented with visual field defects in at least one eye; (2) No cognitive impairment; and (3) Willingness to complete the Generalised Anxiety Disorder Scale (GAD-7)[7] and the Patient Health Questionnaire Depression Scale (PHQ-9) questionnaire[8].

Exclusion criteria: (1) Concurrent retinal diseases; (2) History of other surgical procedures; (3) Concurrent optic neuropathy; and (4) Poor compliance.

Sample size calculation: Based on the formula for calculating the sample size required for multivariate correlation analysis: N = (Uα × S/δ)². Using data from the pilot study, where Uα = 1.96 and S/δ = 7.57, the sample size was determined to be 220[9].

Methods

The GAD-7 and the PHQ-9 were used to assess patients’ levels of depression and anxiety, respectively.

GAD-7: It was developed based on the Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition. It comprises seven items, each scored on a four-point scale (0-3), with a total score ranging from 0 to 21. The classification criteria are as follows: (1) 0-4 points: No anxiety; (2) 5-9 points: Mild anxiety; (3) 10-14 points: Moderate; and (4) 15 points and above: Severe. The score is directly proportional to the severity of the patient’s condition. Related studies[10] have shown that using a cut-off score of 10 points demonstrates good sensitivity (0.64, 95%CI: 0.56-0.72) and specificity (0.91, 95%CI: 0.87-0.93). Therefore, in this study, a total score of ≥ 10 points was defined as GAD-7 positive, indicating the presence of anxiety, while a total score of < 10 points was defined as GAD-7 negative, indicating the absence of anxiety.

PHQ-9: This scale, developed by Kroenke et al[11], is the depression assessment module within a screening tool for mental disorders based on the Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition. It consists of 9 items corresponding to the nine diagnostic criteria for major depressive disorder. These include: (1) Diminished interest or loss of pleasure; (2) Depressed mood; (3) Sleep disturbances; (4) Fatigue; (5) Changes in appetite; (6) Low self-evaluation; (7) Difficulty concentrating; (8) Psychomotor changes (agitation or retardation); and (9) Thoughts of death or suicide. Participants rate the frequency of symptoms experienced in the past two weeks, with options categorized as “not at all” (0 points), “several days” (1 point), “more than half the days” (2 points), and “nearly every day” (3 points). The total score ranges from 0 to 27, categorized as follows: (1) 0-4 points indicates no depression; (2) 5-9 points indicates mild depression; (3) 10-14 points indicates moderate depression; (4) 15-19 points indicates moderately severe depression; and (5) 20-27 points indicates severe depression. Related studies have confirmed[12] that using a cutoff score of 10 points for diagnosing major depression yields a sensitivity of 0.85 (95%CI: 0.79-0.89) and a specificity of 0.85 (95%CI: 0.82-0.87). Therefore, this study defines a total score of ≥ 10 as a PHQ-9 positive result, indicating the presence of depressive symptoms, and a total score of < 10 as a PHQ-9 negative result, indicating the absence of depressive symptoms.

Patients with both GAD-7 and PHQ-9 total scores ≥ 10 were defined as having comorbid depression and anxiety.

Data collection

Data on sociodemographic characteristics (including age, gender, educational level, and family income), ophthalmological clinical features (including disease duration, intraocular pressure, stage of visual field defect, and best-corrected visual acuity), and medication history were collected from the patients.

Standard automated perimetry was performed using the Octopus perimeter (HAAG-Streit, Switzerland, Octopus 900). Staging was based on the results of the patient’s first visual field test after enrollment. According to the European Glaucoma Society staging criteria for Octopus visual fields, a mean deviation (MD) ≤ 6 dB was classified as early stage, 6 dB < MD ≤ 12 dB as moderate stage, and MD > 12 dB as advanced stage[13,14].

Statistical analysis

Statistical analysis was performed using SPSS 26.0 software. For continuous variables, the Shapiro-Wilk test was first conducted. Normally distributed measurement data are expressed as mean ± SD, and comparisons between two groups were made using the independent samples t-test. Count data are expressed as n (%), with comparisons between groups conducted using the χ² test or Fisher’s exact test. Ranked data were analyzed using the Z test. Univariate logistic regression analysis was performed to preliminarily screen sociodemographic and clinical characteristic factors associated with comorbid depression and anxiety. Variables with P < 0.05 were included in a multivariate logistic regression model. The forward stepwise method was used to identify independent influencing factors, and the odds ratio (OR) with its 95%CI was used to assess the strength of influence. The area under the receiver operating characteristic (ROC) curve (AUC) was used to evaluate the predictive efficacy of independent influencing factors. To evaluate the calibration performance of the predictive model, the Hosmer-Lemeshow goodness-of-fit test was employed, and calibration curves were plotted. Internal validation was conducted using the bootstrap resampling method (with 1000 repetitions). A restricted cubic spline (RCS) model was employed to analyze the relationship between independent influencing factors and comorbid depression and anxiety. A P value < 0.05 was considered statistically significant.

RESULTS

Detection rate of comorbid depression and anxiety in chronic glaucoma patients

Based on the GAD-7 and PHQ-9 scores of 220 chronic glaucoma patients, anxiety was detected in 73 cases, with a prevalence rate of 33.18%; depression was detected in 78 cases, with a prevalence rate of 35.45%; comorbid depression and anxiety were detected in 61 cases, with an incidence rate of 27.73%. Based on these results, patients with comorbid depression and anxiety were classified into the comorbid group (n = 61), while the remaining patients were classified into the non-comorbid group (n = 159).

Comparison of clinical data between the comorbid group and the non-comorbid group

There were no statistically significant differences between the two groups in terms of glaucoma subtype, best-corrected visual acuity, intraocular pressure, history of surgery, or types of topical intraocular pressure-lowering eye drops (all P > 0.05). However, in the comorbid group, the proportions of female patients, patients aged ≥ 40 years, those living in urban environments, those with an education level of high school or below, those with a monthly family income ≤ 3000 yuan, those with a disease duration ≥ 10 years, and those with moderate-to-advanced visual field defects were significantly higher than those in the non-comorbid group, while best-corrected visual acuity was lower than that in the non-comorbid group (all P < 0.05; Table 1).

Table 1 Comparison of clinical data between the comorbid anxiety-depression group and the non-comorbid group, n (%)/mean ± SD.

Group		Depression-anxiety comorbidity group (n = 61)	Non-comorbidity group (n = 159)	t/χ2/Z	P value
Gender	Male	21 (34.43)	83 (52.20)	5.588	0.023
	Female	40 (65.57)	76 (47.80)
Age	< 40 years	2 (3.28)	44 (27.67)	17.838	0.000
	40-60 years	24 (39.34)	59 (37.11)
	> 60 years	35 (57.38)	56 (35.22)
Type	Angle-closure	33 (54.10)	76 (47.80)	0.700	0.453
	Open-angle	28 (45.90)	83 (52.20)
Living environment	Urban	49 (80.33)	62 (38.99)	30.131	0.000
	Rural	12 (19.67)	97 (61.01)
Education level	High school or below	51 (83.61)	96 (60.38)	10.729	0.001
	Above high school	10 (16.39)	63 (39.62)
Monthly household income	≤ 3000 yuan/month	45 (73.77)	67 (42.14)	17.651	0.000
	> 3000 yuan/month	16 (26.23)	92 (57.86)
Best corrected visual acuity		0.61 ± 0.16	0.70 ± 0.13	4.456	0.000
Intraocular pressure (mmHg)		15.02 ± 3.01	14.90 ± 3.04	0.284	0.777
Disease duration	< 10 years	15 (24.59)	99 (62.26)	25.062	0.000
	≥ 10 years	46 (75.41)	60 (37.74)
Surgical history	Surgery group	32 (52.46)	86 (54.09)	0.047	0.880
	Non-surgery group	29 (47.54)	73 (45.91)
Types of topical eye drops	≥ 1 type	41 (67.21)	103 (64.78)	0.115	0.755
	< 1 type	20 (32.79)	56 (35.22)
Visual field defect stage	Early stage	11 (18.03)	97 (61.01)	35.908	0.000
	Moderate stage	28 (45.90)	44 (27.67)
	Advanced stage	22 (36.07)	18 (11.32)

Univariate logistic regression analysis of influencing factors for comorbid depression and anxiety

The factors with P < 0.05 identified in section 2.2 were included in the univariate logistic regression analysis. The results showed that age, education level, monthly household income, disease duration, stage of visual field defect, and best-corrected visual acuity were associated with comorbid depression and anxiety (all P < 0.05; Tables 2 and 3).

Table 2 Variable assignment.

Factor	Assignment
Presence of comorbid depression and anxiety	Y	Absent = 0, present = 1
Gender	X1	Male = 0, female = 1
Age (years)	X2	< 40 = 1, 40-60 = 2, > 60 = 3
Living environment	X3	Rural = 0, urban = 1
Education level	X4	Above high school = 0, high school or below = 1
Monthly household income (yuan/month)	X5	> 3000 = 0, ≤ 3000 = 1
Disease duration (years)	X6	< 10 = 0, ≥ 10 = 1
Visual field defect stage	X7	Early stage = 0, moderate stage = 1, advanced stage = 2
Best corrected visual acuity	X8	Enter actual value

Table 3 Univariate logistic regression analysis of influencing factors for comorbid depression and anxiety in patients with chronic glaucoma.

Influencing factor	β	SE	χ2 value	P value	Odds ratio	95%CI
						Lower	Upper
Gender	0.347	0.374	3.217	0.213	1.462	0.115	2.314
Age (years)	1.286	0.892	4.658	0.037	2.324	1.619	2.946
Living environment	0.645	0.332	2.661	0.415	2.422	0.758	3.246
Education level	0.093	0.215	2.109	0.008	1.664	1.012	1.975
Monthly household income (yuan/month)	1.511	0.637	5.384	0.024	1.346	1.106	1.805
Disease duration (years)	0.672	0.103	3.726	0.042	1.223	1.023	1.528
Visual field defect stage	1.024	0.758	2.891	0.016	2.163	1.446	2.248
Best corrected visual acuity	0.835	0.254	4.003	0.033	2.562	1.456	2.859
Constant term	-2.518	0.653	14.87	0.000	-	-	-

Multivariate logistic regression analysis of influencing factors for comorbid depression and anxiety in patients with chronic glaucoma

Factors with P < 0.05 identified in the univariate logistic regression analysis from section 2.3 were included in the multivariate logistic regression analysis. The results indicated that longer disease duration (OR = 1.373, 95%CI: 1.002-1.682), more severe visual field defects (OR = 1.088, 95%CI: 1.012-1.138), and lower monthly family income (OR = 2.254, 95%CI: 1.886-2.634) were independent risk factors for comorbid depression and anxiety in patients with chronic glaucoma (P < 0.05). Based on the multivariate analysis results, a predictive model was constructed with the formula: Y = -3.452 + 0.317 × disease duration + 0.084 × visual field defect stage + 1.659 × monthly family income (Table 4).

Table 4 Multivariate logistic regression analysis of influencing factors for comorbid depression and anxiety in patients with chronic glaucoma.

Influencing factor	β	SE	χ2 value	P value	Odds ratio	95%CI
						Lower	Upper
Disease duration	0.317	0.324	3.416	0.037	1.373	1.002	1.682
Monthly household income	1.659	0.817	2.138	0.012	2.254	1.886	2.634
Visual field defect stage	0.084	0.059	5.092	0.049	1.088	1.012	1.138
Age	1.243	0.632	4.327	0.683	2.367	0.994	2.886
Education level	0.472	0.148	2.759	0.256	1.503	0.769	1.940
Best corrected visual acuity	1.801	0.973	3.871	0.812	1.057	0.345	1.684
Constant term	-3.452	0.921	14.047	0.000	-	-	-

Predictive value of independent influencing factors

ROC analysis showed that the AUC values for predicting comorbid depression and anxiety in chronic glaucoma patients were 0.803 for disease duration, 0.833 for visual field defects, 0.824 for monthly household income, and 0.865 for the combination of all three factors (Figure 1). According to the Hosmer-Lemeshow test, the model fit was good (χ² = 6.732, P = 0.564), with no significant difference between the predicted and actual results; further validation using the bootstrap method revealed an AUC of 0.851 (95%CI: 0.812-0.890), indicating that the model did not suffer from overfitting and was stable and highly reliable (Figure 2).

Figure 1 Receiver operating characteristic analysis. AUC: Area under the receiver operating characteristic curve.

Figure 2  Calibration curve.

An RCS study investigating independent risk factors and dose-response relationships for comorbid depression and anxiety in patients with chronic glaucoma.

RCS analysis indicated that the overall P values and linear P values for disease duration, degree of visual field loss and monthly household income were all < 0.05, and that there was a linear relationship between these factors and the occurrence of depression and anxiety in patients; the longer the disease duration, the more severe the visual field loss and the lower the monthly income, the higher the risk of depression and anxiety (Figure 3).

Figure 3 Restricted cubic spline analysis. A: Restricted cubic spline (RCS) analysis plot of disease duration and comorbid depression-anxiety; B: RCS analysis plot of visual field defect and comorbid depression-anxiety; C: RCS analysis plot of monthly household income and comorbid depression-anxiety. HR: Hazard ratio.

DISCUSSION

There are currently over 76 million people worldwide living with glaucoma, and statistics suggest this number will rise to 112 million by 2040[15]. Chronic glaucoma is characterised by an insidious onset; whilst there are often no obvious symptoms in the early stages, it can lead to severe vision loss and even blindness[16]. This decline in visual function limits patients’ ability to carry out daily activities to a certain extent. Concurrently, patients’ fears of blindness, diminished self-esteem and the financial burden of long-term medication exacerbate their psychological distress[17]. Numerous studies have reported high prevalence rates of anxiety and depression within the glaucoma population[3,4,17]; these conditions often originate in the amygdala, which promotes the release of neurotransmitters and activates the autonomic nervous system, thereby contributing to the pathological progression of glaucoma[18]. When these conditions co-occur, their combined psychophysiological effects accelerate disease progression. Therefore, this study aims to screen for the prevalence of co-morbidity between depression and anxiety in patients with chronic glaucoma and analyse its potential influencing factors, with a view to providing new approaches for clinical intervention.

The study revealed that, out of 220 patients, 73 cases and 78 cases were diagnosed with anxiety and depression respectively, with detection rates of 33.18% and 35.45%. These numbers are broadly consistent with those reported by Berchuck et al[19]. A total of 61 patients met the criteria for both depression and anxiety, representing a prevalence of 27.73%. When comparing clinical data between the comorbid group and the non-comorbid group, the comorbid group had significantly higher proportions of female patients, patients aged ≥ 40 years, those living in urban environments, those with an education level of high school or below, those with a monthly family income < 3000 yuan, those with a disease duration ≥ 10 years, and those with moderate-to-advanced visual field defects, while best-corrected visual acuity was lower than in the non-comorbid group. This suggests that the sociodemographic characteristics, disease severity, and visual functional status of chronic glaucoma patients collectively contribute to the psychological burden of comorbid depression and anxiety. Delavar et al[20] pointed out that insufficient social support is significantly associated with an increased risk of mental health disorders in glaucoma patients. Lower levels of social support in women compared with men significantly increase the risk of comorbid depression and anxiety in female patients. The prevalence of glaucoma has been reported to increase with age[21]. Advanced age leads to decline in physical function and increases the burden of comorbidities such as hypertension and diabetes, thereby increasing the risk of comorbid anxiety and depression[22]. Glaucoma patients with lower education levels have fewer economic resources and pay less attention to their own health issues, making them more susceptible to comorbid depression and anxiety[23].

Logistic regression analysis revealed that longer disease duration, more severe visual field defects, and lower monthly family income are independent risk factors for comorbid depression and anxiety in patients with chronic glaucoma. Patients with lower income have poorer access to medical resources and face significant financial pressure from the lifelong treatment burden, making it difficult for them to accept treatment and recover comfortably, thereby increasing the psychological stress of comorbid depression and anxiety[24]. Long-term disease duration leads to persistent activation of the hypothalamic-pituitary-adrenal (HPA) axis and chronically abnormal levels of glucocorticoids such as cortisol. High cortisol levels are neurotoxic, damaging the patient's hippocampus and further negatively impacting HPA axis function through negative feedback, creating a vicious cycle of neuroendocrine dysfunction that promotes the development of comorbid depression and anxiety[18]. Furthermore, prolonged psychological stress can lead to dysregulation of cortisol levels, which in turn upregulates glucocorticoid receptor expression, reduces aqueous humor outflow, increases intraocular pressure, exacerbates sympathetic overactivation, thereby increasing vascular resistance and reducing optic nerve perfusion, worsening optic nerve damage. Additionally, stress-induced parasympathetic inhibition affects the body’s ability to recover from stress and maintain normal intraocular pressure and vascular homeostasis, subsequently stimulating the production of pro-inflammatory cytokines such as interleukin-1 beta, accelerating the activation of glial cells, disrupting the blood-retinal barrier, and thus exacerbating retinal and optic nerve damage, forming a vicious cycle[25]. Severe visual field defects significantly impair the overall visual function of glaucoma patients, making daily activities such as reading and driving extremely difficult, severely eroding patients’ self-efficacy, and thereby accelerating the development of comorbid depression and anxiety[26]. Research by Ramesh et al[27] showed that accelerated progression of visual impairment, advanced disease stage, female gender, and older age are all risk factors for anxiety and depression in glaucoma patients, further validating our findings. It should be noted that this study has a potential confounding factor that was not included in the analysis. Although all patients in both groups used topical intraocular pressure-lowering eye drops with no statistical difference in the types of medications, drugs such as beta-blockers can be systemically absorbed through the nasolacrimal duct and may cross the blood-brain barrier, thereby affecting mood. Therefore, the specific types of topical medications may influence the psychological status of glaucoma patients. Future studies should collect detailed information on medication regimens to better control for this potential effect.

ROC analysis demonstrated that the AUC values for disease duration, visual field defect stage, and monthly household income were 0.803, 0.833, and 0.824, respectively. The combined AUC of the three factors was 0.865, indicating good overall predictive ability. A longer disease duration implies that patients have been subjected to chronic disease-related stress for a longer period, with the HPA axis remaining in a state of prolonged activation. More severe visual field defects not only indicate greater damage to retinal ganglion cells but also, to some extent, exacerbate patients’ fear of blindness and their dependence on others for daily functioning, thereby promoting a positive stress cycle. Conversely, low household income constitutes a persistent source of psychosocial stress due to limited access to medical resources and increased financial pressure. These factors collectively influence HPA/sympathetic-adreno-medullar axis function, prompting prolonged and excessive secretion of glucocorticoids and catecholamines. This, in turn, leads to exacerbated oxidative stress, impaired mitochondrial function and intensified neuroinflammatory responses, ultimately accelerating the process of retinal ganglion cell apoptosis. Calibration curve analysis indicated that the combined model exhibited good fit consistency. RCS analysis further confirmed that there is a linear association between disease duration, visual field defect staging, household monthly income, and depression and anxiety in glaucoma patients: The longer the disease duration, the more severe the visual field damage, and the lower the household income, the greater the likelihood of patients experiencing both depression and anxiety. This indicates that the occurrence of comorbid depression and anxiety results from the interaction between the disease itself and socio-economic conditions, providing a reference for clinical psychological screening and early intervention. Glaucoma patients face multiple factors, including progressive vision loss, long-term disease management, concerns about blindness, financial pressures associated with medication, and a decline in quality of life and psychological well-being, which ultimately lead to increased levels of depression and anxiety[28]. This indicates that clinicians, in the course of treatment, need to monitor changes in patients' visual acuity, intraocular pressure, and visual field to better understand their negative emotional states such as anxiety and depression. Simultaneously, they should also gather detailed information about the patients’ personal circumstances and living environment, providing psychological counseling and health education alongside medical treatment to enhance the therapeutic outcomes of glaucoma through combined psychological and physiological approaches. Based on the independent risk factors identified in this study, we recommend prioritizing psychological screening for glaucoma patients with disease duration ≥ 10 years, moderate-to-advanced visual field defects, or monthly income ≤ 3000 yuan. For patients who screen positive (GAD-7/PHQ-9 score ≥ 10), ophthalmologists can provide brief psychoeducation and low-intensity interventions such as mindfulness meditation, and refer severe cases to mental health specialists. Implementing this risk-stratified pathway in routine glaucoma care may improve the detection rate and initial management capacity of comorbid depression and anxiety.

CONCLUSION

In summary, depression and anxiety are prevalent among patients with chronic glaucoma, with a longer disease duration, more severe visual field defects and poorer economic circumstances all identified as independent risk factors. Clinically, there is a need to strengthen psychological assessment and comprehensive management for this patient population. This study has some limitations; it was a single-centre retrospective study, and the variables included focused primarily on demographic characteristics and routine ophthalmic indicators, without involving pathophysiological or biomarker data. Although internal validation of the predictive model using the bootstrap method revealed no significant tendency towards overfitting, further testing using external data is lacking. It is therefore necessary to conduct multicentre prospective studies in the future, incorporating multidimensional indicators such as molecular biology, in order to elucidate more thoroughly the intrinsic relationship between depression and anxiety and the progression of glaucoma.