Decision Tree Aims to Monitor Depression in Caregivers of Children With Glaucoma

Little Girl at Eye Testing Examination
Side view portrait of cute little girl looking at slit lamp machine during medical check up in eye clinic
System provides steps for identifying quality of life reductions in parents of children who have undergone glaucoma surgeries.

Glaucoma in pediatric patients can affect their caretakers’ quality of life (QOL), particularly when children have undergone more than 2 glaucoma surgeries, according to a study published in the American Journal of Ophthalmology.

Patients with childhood glaucoma, the most common cause of childhood blindness, tend to need lifelong follow-up and caregivers’ assistance with daily living activities. Caregivers’ wellbeing can influence the quality of care they can provide. The study’s investigators developed and investigated the utility of a decision tree model (DTM) for identifying caregivers at greatest risk of depression and anxiety.

The research team examined medical records of patients with primary childhood glaucoma, secondary childhood glaucoma, or glaucoma suspect (GM) participating in the Seoul Childhood Glaucoma Quality of Life Study (Seoul CG-QOL Study) at Seoul National University Children’s Hospital. Caregivers of the patients (42 primary glaucoma, 51 secondary glaucoma, 36 GS) completed the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) assessment.

Congenital cataract surgery (n=22), Sturge-Weber syndrome (n=14), and uveitis (n=4) were the most common causes of secondary glaucoma.

PHQ-9 scores and GAD-7 scores were higher among caregivers of children with primary glaucoma compared with those of children with secondary childhood glaucoma or GS, but the differences were not statistically significant.

There were 10 caregivers with moderate-to-severe depressive symptoms (PHQ-9 score ≥10, 5 primary childhood glaucoma group, 4 secondary childhood glaucoma group, 1 GS group) and 11 caregivers with moderate-to-severe anxiety symptoms (GAD-7 ≥11 6 primary childhood glaucoma group 5 secondary childhood glaucoma group).

The investigators found that the DTM’s predictions for moderate-to-severe depressive symptoms via PHQ-9 had balanced accuracy of 0.875, sensitivity of 0.778, and specificity of 0.972. More than 2 glaucoma surgeries and patients who have visual acuities (VA) in their better eye worse than 0.4 logMAR may indicate that clinicians should strongly suspect caregivers have symptoms of depression, according to the study.

The DTM’s predictions for moderate-to-severe anxiety symptoms via GAD-7 scores had balanced accuracy of 0.880, sensitivity of 0.800, and specificity of 0.960. Physicians should strongly suspect these symptoms in caregivers if their child has VA worse than 0.5 logMAR or if they have undergone more than 1 glaucoma surgery.

“Caregiver burden is an important factor in many chronic diseases, including childhood glaucoma,” researchers report. “Caregivers of children with glaucoma are likely to experience decreased QOL. In clinical practice, evaluation of the number of glaucoma surgeries and VA in the better eye can be a useful screening tool in predicting mental illness in caregivers of children with glaucoma.”

Limitations of the study include possible inclusion of caregivers with pre-existing history of depression or anxiety disorders, lack of analysis of family structure, and no evaluation of health-related quality of life (QOL) in children with glaucoma.


Wy S, Choe S, Lee JY, et al. Decision tree algorithm-based prediction of vulnerability to depressive and anxiety symptoms in caregivers of children with glaucoma. Am J Ophthalmol. Published online February 13, 2022. doi:10.1016/j.ajo.2022.01.025