Beyond vision loss: psychological distress as a potential pathway linking social support to vision-related quality of life in glaucoma

To investigate the association between vision-related quality of life (QoL) and psychosocial factors, including social support, psychological distress in patients with primary open-angle glaucoma (POAG), and to examine whether psychological distress may explain some of the associations between social support and QoL. In this cross-sectional observational study, 124 outpatients diagnosed with POAG completed a battery of questionnaires between August 2024 and January 2025. The 25-Item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25), Social Support Rating Scale (SSRS) and 4-Item Patient Health Questionnaire (PHQ-4) were used to assess the vision-related QoL, social support, and psychological distress respectively. Socio-demographic information was concurrently gathered. Univariate analyses revealed that lower educational attainment ( P < 0.001), higher economic burden of glaucoma treatment ( P < 0.001), chronic comorbidity ( P = 0.034), and former or current smoking status ( P = 0.004) were associated with poorer QoL. In multiple regression analysis, after PHQ-4 was entered, psychological distress, economic burden, and smoking remained significant, whereas the associations of social support and education with QoL were attenuated. Mediation analysis revealed a significant indirect effect of social support on QoL through psychological distress ( ab = 0.185, P < 0.001), while the direct effect was not statistically significant ( c’ = 0.312, P = 0.081). These results suggest that psychological distress may account for a substantial part of the observed association between social support and vision-related QoL. The association between social support and vision-related QoL in POAG patients may be partly attributable to psychological distress. These findings suggest potential value in integrating psychological distress screening into routine glaucoma care, though longitudinal studies are needed to confirm directionality. Anxiety and depression may represent a key psychological link between social support and vision-related quality of life in primary open-angle glaucoma.