Stressed Eyes May Require a Holistic, Empathetic Approach From Optometrists

A young girl is sitting on the couch at home with her head in her hands.
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Cecelia Koetting, OD, and Dennis Pardo, OD, LCSW discuss the effects of excess stress on eye-related quality of life outcomes.

Stressed eyes — those of patients with anxiety or other psychological conditions — can take on physical symptoms such as increased inflammation, and have worse disease. Research shows that stress may result in visual acuity changes, increased intraocular pressure (IOP), twitching, dry eye disease (DED), or temporary peripheral vision reduction.2 While optometrists can issue medications or recommendations to keep eyes in top health, few are formally trained in helping patients manage anxiety. Taking a root cause analysis into consideration could result in a referral to a therapist or other mental health professional. But, the necessary first step in this process must be for optometrists to recognize stress and anxiety in their chairs.   

With more than half of Americans reporting they feel stressed during the day — 57% report feeling paralyzed by it — optometrists are likely to encounter such patients.1 

Identifying ocular symptoms resulting from anxiety and suggesting potential mechanisms for coping may help to reduce or alleviate these signs and symptoms and improve patient quality of life. 

Stress Can Instigate Myokymia

Not all stress-related ocular symptoms will necessarily result in diminished vision or pain, but they can still create a terrifying experience for patients who unexpectedly experience them, according to Dennis Pardo, OD, LCSW, a multi-year veteran of optometry who currently practices as a psychotherapist. 

“The number one thing that comes to mind [regarding stress-related symptoms] is myokymia. A lot of patients get this and are scared that something is seriously wrong. It feels like your eye is going to pop out of your head,” Dr Pardo explained. While excess caffeine consumption and a lack of sleep are not necessarily associated with stressed eyes, they frequently accompany anxiety and exacerbate myokymia, he said. 

While botulinum toxin injections may be effective in persistent cases, reducing stress, limiting alcohol and caffeine consumption, and getting more rest will frequently resolve the condition.3  

Intraocular Pressure Changes With Stress

Significant IOP changes can result from excess anxiety — a particular concern for individuals with glaucoma, even those who strictly adhere to treatment regimens.4 A 2020 investigation evaluating cortisol response to psychological stimulation found that induced stress resulted in IOP increases greater than 2 mm Hg among 35% of participants.5 While anxiety does not cause primary open-angle glaucoma, it may be a contributing factor in nonadherence to glaucoma control regimens and failure to attend follow-up visits.2 Stress can, however, precipitate an acute angle-closure attack and contribute to optic nerve damage.2

Stress Kicks Off The Inflammatory Process 

These elevated cortisol levels do not exclusively wreak havoc on the optic disc, but the retina and ocular surface as well, according to Cecelia Koetting, OD, who not only specializes in dry eye disease, glaucoma, and diabetic eye care, but helps others to manage their stress as a yoga instructor. 

“Stress makes your body release excess cortisol, which causes inflammation and has been linked to central serous retinopathy, worsening of dry eye disease, and flare ups or incidence of other inflammatory ocular problems such as uveitis,” she said. 

Since increased stress can exacerbate vision loss, which is itself a known cause of high anxiety, it can be considered both a causative element and risk factor for visual decline.6 A repeating pattern may result in which mental stress impairs ocular structural vascular functioning, vision loss occurs and triggers additional anxiety.6 Ending the cycle early is crucial for allowing patients to retain their vision and maintain their quality of life.   

Patients with stressed eyes may experience a diminished quality of life resulting from DED. Digital screen use, medications, and age- and sex-related characteristics all affect DED, but psychological factors may independently influence DED or exacerbate it in individuals with confounding risk factors. A 2015 study that included 121 individuals with DED showed that depression (odds ratio [OR], 2.06; 95% CI, 1.30-3.27), anxiety (OR, 2.66; 95% CI, 1.67-4.23), and stress (OR, 2.33; 95% CI, 1.48-3.67) all doubled the risk of DED.7 Another investigation revealed a higher prevalence of DED among paramedical workers at a university hospital — a career associated with increased stress. Compared with an estimated DED prevalence between 10% and 30% in the general population, DED prevalence was 42.7% among these individuals.8 Overall, higher stress, determined by visual analog scale (P <.001) and perceived stress scale-4 scores (P =.009), is significantly associated with DED.

Discuss Stress Management With Your Patients

Patients may have the expectation that they will leave an optometrist’s chair with a prescription for topical or oral medications, compresses, or suggestions for over-the-counter remedies for their ocular symptoms. While these may be appropriate in many circumstances, ocular symptoms may not resolve so easily in stressed eyes without addressing the source of the stress. Initiating this conversation may be difficult for clinicians who are highly skilled in treating ocular pathology, but lack formal skill sets for resolving stress. 

Dr Pardo acknowledged that this may not be an easy task. 

“Familiarizing yourself with basic mental health issues is really, really important. When it comes to initiating a conversation about anxiety or anything else that might indicate mental health, it’s not an easy thing to do. This is not what we do day in and day out,” he said.

He suggested beginning the conversation with an empathetic approach that shows concern for patients’ well-being, something along the lines of “I’m noticing it looks like you might be a little bit nervous, so I just want to pause here and ask you, is everything okay? Is there anything I can do to make you feel more comfortable?” 

The intersection of optometry and other medical specialties is not an uncommon place for an optometrist to find themselves, given the eye exam’s ability to detect diabetes, high blood pressure, rheumatoid arthritis, cancer, and other pathologies.9 According to Dr Koetting, assisting patients with stress management is not necessarily overstepping one’s boundaries as an optometrist. It’s merely an exercise in comanagement — one that should be performed with other qualified health care professionals. 

“Don’t take the task of counseling on yourself,” she said. “Ask the patient if they are seeking professional guidance from a therapist or even meeting with a psychologist to discuss medication to help manage anxiety or stress. If they aren’t, depending on the situation, it may be good to suggest this to the patient or even refer them. This is similar to sending an uncontrolled diabetic patient to an endocrinologist and a dietician; we are seeking help from other specialists in managing our patients’ health to mitigate ocular effects.”  

Recommending therapies for stressed eyes cannot harm patients — worst case scenario, they do nothing to improve their quality of life — and techniques such as breathing, mindfulness meditation, and palming may be noninvasive ways of reducing stress, Dr Koetting argued. 

Similarly, Dr Pardo explained the value of therapeutic treatments that do not involve pharmaceuticals. 

“What I recommend for anxiety is talk therapy and mindfulness,” he said. “Mindfulness exercises are really my go-to for patients with anxiety in terms of things you can do from a non medication standpoint.” 

Research supports Dr Pardo’s and Dr Koetting’s assertions that mindfulness therapies can help patients achieve both quality of life and ocular symptom improvements. A 2022 investigation found that mindfulness-based stress reduction techniques caused IOP reduction, improved optic nerve head blood flow, decreased serum cortisol levels, and improved quality of life compared with individuals assigned to a control group.10  

The Power of Personal Choices

Behavior modification and investing in certain ophthalmic lens features may also potentially improve ocular symptoms and reduce stress, according to Dr Koetting. Antireflective coatings and polarized sunglass lenses can reduce eye strain and protect against ultraviolet light, respectively. Spending time outdoors can improve well-being and positively affect mood, but detrimental effects on the eyes, including age-related macular degeneration (AMD), cataracts, and eyelid cancers are causes for concern.11, 12 Consuming a healthy and balanced diet, smoking cessation, and limiting digital screen time, particularly before bedtime, can also improve ocular symptoms and alleviate stress, Dr Koetting asserted.     

As National Stress Awareness Month comes to a close, clinicians of all specialties should take a moment to consider how stress and anxiety affect their patients and consider ways to help them cope. This may require a new mindset, one with an open-mindedness to holistic treatment and a willingness to get personal. 

Optometrists may not be able to control common stressors, which include political climate, inflation, or a patient’s work-associated conditions, but an empathetic approach that offers potential stress-reducing recommendations may improve eye-related outcomes in patients with high anxiety.1 And while an advanced degree in psychology can improve informed clinical decision making, this level of training is not necessary for clinicians to help patients with stressed eyes achieve an improved quality of life.     


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