Objective: The objective was to assess the profile of different types of glaucoma in a University Health Centre in Al‑Ahsa, Saudi Arabia.Materials and Methods: It is a retrospective study in which the files of the patients at King Faisal University Health Centre were reviewed. The data collected included: Age, sex, race, visual acuity, the slit lamp examination findings, the intraocular pressure (IOP) as the average of 3 readings, the cup‑to‑disc ratio (CDR), the visual field changes, and the details of treatment received.Results: Eighty glaucomatous eyes from 50 patients were included in the study. The mean age was 54.8 ± 12.7 years, and the mean IOP was 19 ± 3.9 mmHg that ranged from 11 to 28 mmHg. The mean CDR mean was 0.48 ± 0.16 that ranged between 0.3 and 0.9. Ninety‑one percent of the visual field defects were arcuate scotomata. Primary open‑angle glaucoma (POAG) (60%) was the most predominant type of glaucoma, followed by primary angle closure glaucoma (ACG) (21.3%), secondary OAG (7.5%), and secondary ACG (6.3%). As for the anti‑glaucoma medications, 88% of the studied patients were on more than one medicine.Conclusion: This pilot study has demonstrated that POAG may be the predominant type of glaucoma in Al‑Ahsa, Kingdom of Saudi Arabia (KSA). Apopulation‑based study with a larger sample size is warranted to confirm the outcome and to provide a baseline data on the prevalence of types of glaucoma in this region of KSA.Keywords: Glaucoma, glaucoma types, prevalence, Saudi Arabi

Al Hathloul, Hisham Sameer

Al Naim, Mansour Abdullah

Al Rashed, Abdullatif Sami

Al Shehab, Khalid Abdullah

Al Subaie, Hamad Abdulaziz

Aleem, Ansari Mukhtar

Kaliyadan, Kaberi Feroze

English

AJOL - African Journals Online

Nigerian Journal of  Ophthalmology / Jan-Jun 2015 / Vol 23 / Issue 112Address for correspondence  Dr. Ansari Mukhtar Aleem, Division of Biomedical Sciences, College of Medicine, King Faisal University, Al-Ahsa, Kingdom of Saudi Arabia. E-mail: aaleem@kfu.edu.saWorldwide, glaucoma is the leading cause of irreversible blindness, affecting more than 60 million people which is projected to increase to 76.0 million by 2020 and 111.8 million by 2040.[3] Glaucoma disproportionally affects people residing in Asia and Africa.[3] The prevalence and the type of glaucoma vary in different regions of the world. The Middle East region, to which Kingdom of Saudi Arabia (KSA) belongs, is expected to have over 2.2 million people with glaucoma by 2020 of which two million will be OAG.[4] This estimated figure for the Middle East region is based on the prevalence models for the European people due to lack of studies from this region. More studies are required in the Middle Eastern region to have more accurate statistics.[4] Though, there are few studies from different regions of KSA,[5‑7] to our knowledge there is no study regarding prevalence and the types of glaucoma from the Eastern region of KSA. The present pilot study is a small endeavor to estimate the prevalence and the types of glaucomas in INTRODUCTIONGlaucoma is defined as a group of ocular disorders with multi‑factorial etiology united by a clinically characteristic intraocular pressure (IOP)‑associated optic neuropathy.[1] The most clinically useful classification of glaucoma into open angle glaucoma (OAG) and angle closure glaucoma (ACG) was devised by Barkan in 1938.[2] OAG and ACG are further subdivided into primary and secondary glaucomas depending on the presence of underlying contributory factors.Types of Glaucoma in a University Health Centre in Al‑Ahsa, Saudi Arabia: A Pilot StudyAbdullatif Sami Al Rashed, Hamad Abdulaziz Al Subaie, Hisham Sameer Al Hathloul,   Khalid Abdullah Al Shehab, Mansour Abdullah Al Naim, Kaberi Feroze Kaliyadan1,   Ansari Mukhtar Aleem2College of Medicine, King Faisal University, 1Department of Ophthalmology, College of Medicine, King Faisal University, 2Division of Biomedical Sciences, College of Medicine, King Faisal University, Al-Ahsa, Kingdom of Saudi ArabiaABSTRACTObjective:	The	objective	was	 to	assess	 the	profile	of	different	 types	of	glaucoma	 in	a	University	Health	Centre	 in	Al‑Ahsa,	Saudi Arabia. Materials and Methods:	 It	 is	a	retrospective	study	 in	which	the	files	of	 the	patients	at	King	Faisal	University	Health	Centre	were	reviewed.	The	data	collected	 included:	Age,	sex,	 race,	visual	acuity,	 the	slit	 lamp	examination	findings,	the	 intraocular	pressure	 (IOP)	as	 the	average	of	3	 readings,	 the	cup‑to‑disc	 ratio	 (CDR),	 the	visual	field	changes,	and	 the	details of treatment received. Results: Eighty glaucomatous eyes from 50 patients were included in the study. The mean age was 54.8 ± 12.7 years, and the mean IOP was 19 ± 3.9 mmHg that ranged from 11 to 28 mmHg. The mean CDR mean was	0.48	±	0.16	 that	 ranged	between	0.3	and	0.9.	Ninety‑one	percent	of	 the	visual	 field	defects	were	arcuate	scotomata.	Primary open-angle glaucoma (POAG) (60%) was the most predominant type of glaucoma, followed by primary angle closure glaucoma (ACG) (21.3%), secondary OAG (7.5%), and secondary ACG (6.3%). As for the anti-glaucoma medications, 88% of the studied patients were on more than one medicine. Conclusion: This pilot study has demonstrated that POAG may be the predominant type of glaucoma in Al-Ahsa, Kingdom of Saudi Arabia (KSA). A population-based study with a larger sample size is warranted	to	confirm	the	outcome	and	to	provide	a	baseline	data	on	the	prevalence	of	types	of	glaucoma	in	this	region	of	KSA.Keywords: Glaucoma, glaucoma types, prevalence, Saudi ArabiaOriginal articleAccess this article onlineQuick Response CodeWebsite:www.nigerianjournalofophthalmology.comDOI:10.4103/0189-9171.164495 Al Rashed, et al.: Types of glaucoma in Al‑AhsaNigerian Journal of  Ophthalmology / Jan-Jun 2015 / Vol 23 / Issue 1 13and 11 (22%) females. Saudi nationals constituted 76% of the sample while the other 24% were of different nationalities. The mean age of the studied sample was 55 ± 12.8 years ranging from 18 to 76 years [Table 1].The most common type of glaucoma in the sample reviewed was primary OAG (POAG) (60%), followed by primary ACG (PACG) (21.3%), secondary OAG (7.5%), and secondary ACG (6.3%) [Table 2]. The visual acuity ranged from 1 to “no light perception” and the refraction was emmetropia (34%), myopia (26%), and hypermetropia (40%). As for the mode of presentation, 24% of the patients were incidentally discovered during routine eye evaluation, whereas 76% presented with visual disturbances [Table 3].The mean IOP of the studied sample was 19 ± 3.9 that ranged from 11 to 28 mmHg. The mean CDR mean was 0.5 ± 0.2 that ranged between 0.3 and 0.9 [Table 1]. Ninety‑one percent of the visual field defects were arcuate scotomata and 6% were a tubular field. The studied patients were receiving anti‑glaucoma medicines ranging from one to four with 88% receiving more than one medication. Of these, 58% were receiving two medications, 26% three medications, whereas 4% of the patients were receiving four medications [Table 3].Al‑Ahsa, a municipality in the Eastern region of KSA. Such studies are imperative in establishing a baseline and clarifying the current needs, that would help the health policy makers to arrange their priorities for effective intervention in terms of training and other important health policy measures at the regional health level.[5] More of such regional studies could form the basis for a national prevalence indicator of different types of glaucomas and serve as a benchmark for glaucoma‑related health needs.MATERIALS AND METHODSThe files of glaucoma patients from the King Faisal University Health Centre, Al‑Ahsa were retrospectively reviewed in the month of April and May 2013. The study had been submitted and approved by the Research and Ethical Committee at the College of Medicine, King Faisal University. For the purposes of the study, Glaucoma was defined as per ISGEO criteria. From each file, the following data were collected: Patient history with emphasis on age, sex and race, the chief complaints, and family history of glaucoma. The presence of diabetes, hypertension, ischemic heart diseases or other vascular diseases were also noted. Furthermore, recorded were: Visual acuity, slit lamp examination findings, the IOP as the average of 3 readings (Goldmann applanation tonometer), the cup‑to‑disc ratio (CDR), and the visual field defects. The optic disc was examined with the + 90 D lens (Volk) after pupil dilation. The ratio of the maximal vertical length of the cup and the maximal vertical length of the disc was assessed, and this was calculated as the vertical CDR. The octopus automated perimeter was used for analyzing the visual field defects. The visual field indices, the mean defect and corrected loss variance were compiled. The angles of the anterior chamber; whether open, closed or narrow were recorded using the Goldmann’s 4 mirror gonioscope. Angle grading was done according to the Shaffer’s system of angle grading. The presence of peripheral anterior synechiae or neovascularization were noted. The iris insertion and the profile of the iris were assessed using the Spaeth’s system. The type of glaucoma and the glaucoma management was also noted. Many of the files were lacking the necessary information and were excluded from the study. Furthermore, some cases diagnosed as glaucoma who were eventually found not to be really glaucomatous were also excluded. The results were tabulated, and statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 17 (SPSS inc., Chicago, Il, USA).RESULTSA total of 80 glaucomatous eyes for 50 patients were included in the study, of these 39 (78%) were males Table 1: Age, IOP, CDR of the studied sampleVariables n Minimum Maximum Mean (SD)Age 80 18 76 54.88 (12.76)IOP 80 11.0 28.0 19.02 (3.91)CDR 80 0.3 0.9 0.487 (0.16)SD: Standard deviation, IOP: Intraocular pressure, CDR: Cup‑to‑disc ratioTable 2: Variables obtained from the studied sampleVariables n (%)SexMale 39 (78)Female 11 (22)RaceSaudi 38 (76)Non‑Saudi 12 (24)Visual field defectArcuate 73 (91.3)Tubular 5 (6.3)Nonspecific 2 (2.5)AngleOpen 61 (76.3)Closed 5 (6.3)Narrow 14 (17.5)Type of glaucomaPOAG 48 (60)PACG 17 (21.3)Secondary POAG 6 (7.5)Secondary PACG 5 (6.3)Glaucoma suspect 4 (5)POAG: Primary open‑angle glaucoma, PACG: Primary angle‑closure glaucomaAl Rashed, et al.: Types of glaucoma in Al‑AhsaNigerian Journal of  Ophthalmology / Jan-Jun 2015 / Vol 23 / Issue 114DISCUSSIONIn the present study, 78% of the patients were males and 76% of the study population was composed of Saudi nationals. A similar study from Qatar had 54.8% nationals while the rest of the participants were expatriates.[8] Study by Al Obeidan et al.[6] had 41% males while the study from India found no significant gender difference in the prevalence of glaucomas.[9]In the present study, the mean age of presentation of glaucoma was around 55 years which is less than the figure obtained in other studies from KSA[6] (62 years) and China[10] (64.6 years). However, our result is similar to the mean age of 56.4, 55.08, and 53.4 years obtained in studies from KSA,[5] Nepal,[11] and Cameroon,[12] respectively. A study in India reported the mean age of presentation with glaucoma as 51.44 years[9] whereas a study from Africa reported the mean age as 50 years.[13] There are studies which report the mean age of presentation to be lower than 50 years.[14,15] These results demonstrate that the major focus of glaucoma screening efforts should be directed to the middle‑aged population and ideally, those above 40 years.The main determinants of glaucomas are IOP, disc changes, and visual field changes. In the present study, the mean IOP of 19.94 mmHg and 19.23 mmHg was observed for the patients with POAG and PACG, respectively. Al Obeidan et al.[6] observed the IOP of 27 mmHg for POAG and 29 mmHg for PACG in Saudi patients. Mean IOP of 26.5 mmHg was also observed in a study from the Western region of Saudi Arabia.[5] A population‑based survey among the Bai Nationality in rural China reported the mean IOP of 25.3 mmHg among the subjects with POAG.[10] The low IOP observed in the present study may be due to the treatment of the condition where 88% patients were already receiving more than one medications.In this study, the mean CDr was found to be 0.49 (POAG) and 0.53 (PACG). Al Obeidan et al.[6] found a mean CDR of 0.73 and 0.72 in POAG and PACG, respectively with the highest mean CDR of 0.81 in Juvenile Glaucoma patients. 69% had CDR between 0.4 and 0.8, 14% had CDR of > 0.9.[16] In a study by Florcruz et al.,[17] vertical CDR was found to be 0.7. This lower level of CD changes in our study could be due to easy medical accessibility and early presentation to the medical setup.Visual field defects are arcuate in 73% of patients and tubular in 5% of patients in our study. Arcuate visual field defects are the characteristic field changes of POAG, which is the most common type of glaucoma in our study.In our study, most of the patients underwent medical treatment. The Collaborative Initial Glaucoma Treatment Study[18] showed that there was no difference between initial medical versus surgical therapy in visual preservation but that subjects preferred medical therapy primarily because the side effects associated with initial surgical therapy are more troublesome than those found with medical therapy. Overall, initial medical therapy remains the treatment of choice for most patients with OAG. Initial management of PACG is also medical. In about 88% of the patients in this study, more than one eye drops were used. In a study from Qatar, three‑fourths of the patients were using local drops, and 6% underwent surgery.[8] There was a time when maximal medical therapy included every available glaucoma medication including beta blockers, pilocarpine, and epinephrine. Given diminishing returns with each additional medication, it is rarely beneficial for a patient to be receiving two or more glaucoma drugs at the same time.[19]In our study, the most common type of glaucoma was POAG (60%). The prevalence of POAG was found to range between 14.4% and 69.3% in different studies around the world.[6,16,17,20] According to Quigley and Broman,[4] POAG is the most prevalent of all types of glaucomas. A study from Qatar[8] had 65.7%, whereas the Oman[21] eye study had 40.6% POAG. Our study corresponds fairly close to the study from Qatar. This could also be explained by the close geographical proximity of Al‑Ahsa region to Qatar. In the present study, 24% patients accidently discovered the disease and 76% presented to the hospital after the onset of symptoms. More awareness is needed in the community about the seriousness of glaucoma as a cause of blindness. Health education regarding POAG should be conducted at the community level to raise the level of awareness about this condition.Table 3: Mode of presentation, errors of refraction, and medication used in the studied sampleVariables n (%)Mode of presentationAccidentally discovered 12 (24)Visual symptoms 36 (76)Errors of refractionEmmetropia 17 (34)Myopia 13 (26)Hypermetropia 20 (40)Medications usedOne medication 6 (12)Two medications 29 (58)Three medications 12 (24)Four medications 3 (6)Al Rashed, et al.: Types of glaucoma in Al‑AhsaNigerian Journal of  Ophthalmology / Jan-Jun 2015 / Vol 23 / Issue 1 15In the present study, 21.3% of the glaucoma patients have PACG. The prevalence of PACG has been found to vary from 5.3% to 46.6% in different studies.[6,16,17,20] This shows a huge variation in the prevalence of PACG, which could be explained by genetic predisposition, race, and other environmental factors.In summary, POAG and PACG are the two most common types of glaucomas presenting to our hospital. In our study, more than half of the patients were having POAG. Different studies around the world show preponderance of different types of glaucoma, some showing POAG to be the most common[5,8,21] and some showing PACG to be more common.[6,9] Therefore, population‑based epidemiological surveys are required to find out the true prevalence of the different types of glaucomas in this country and to implement measures for their early detection and treatment.ACKNOWLEDGMENTSThe authors are indebted to Prof. Mohammed Saad Morsi (Ophthalmologist) for his guidance and support toward the study from its inception to its completion. His vast knowledge and experience helped the authors in data collection and analysis.REFERENCES1. Casson RJ, Chidlow G, Wood JP, Crowston JG, Goldberg I. Definition of glaucoma: Clinical and experimental concepts. Clin Experiment Ophthalmol 2012;40:341-9.2. Barkan O. Glaucoma: Classification, causes, and surgical control. Results of microgonioscopic research. Am J Opthamol 1938;2:1099-114.3. Tham YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY. Global prevalence of glaucoma and projections of glaucoma burden through 2040: A systematic review and meta-analysis. Ophthalmology 2014;121:2081-90.4. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol 2006;90:262-7.5. Eid TM, el-Hawary I, el-Menawy W. Prevalence of glaucoma types and legal blindness from glaucoma in the western region of Saudi Arabia: A hospital-based study. Int Ophthalmol 2009;29:477-83.6. Al Obeidan SA, Dewedar A, Osman EA, Mousa A. The profile of glaucoma in a Tertiary Ophthalmic University Center in Riyadh, Saudi Arabia. Saudi J Ophthalmol 2011;25:373-9.7. Alanazi FF, Song JC, Mousa A, Morales J, Al Shahwan S, Alodhayb S, et al. Primary and secondary congenital glaucoma: Baseline features from a registry at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. Am J Ophthalmol 2013;155:882-9.8. Al-Mansouri FA, Kanaan A, Gamra H, Khandekar R, Hashim SP, Al Qahtani O, et al. Prevalence and determinants of glaucoma in citizens of qatar aged 40 years or older: A community-based survey. Middle East Afr J Ophthalmol 2011;18:141-9.9. Palimkar A, Khandekar R, Venkataraman V. Prevalence and distribution of glaucoma in central India (Glaucoma Survey 2001). Indian J Ophthalmol 2008;56:57-62.10. Zhong H, Li J, Li C, Wei T, Cha X, Cai N, et al. The prevalence of glaucoma in adult rural Chinese populations of the Bai nationality in Dali: The Yunnan Minority Eye Study. Invest Ophthalmol Vis Sci 2012;53:3221-5.11. Thapa SS, Thapa R, Paudyal I, Khanal S, Aujla J, Paudyal G, et al. Prevalence and pattern of vitreo-retinal diseases in Nepal: The Bhaktapur glaucoma study. BMC Ophthalmol 2013;13:9.12. Ellong A, Mvogo CE, Bella-Hiag AL, Mouney EN, Ngosso A, Litumbe CN. Prevalence of glaucomas in a Black Cameroonian population. Sante 2006;16:83-8.13. Ntim-Amponsah CT, Amoaku WM, Ofosu-Amaah S, Ewusi RK, Idirisuriya-Khair R, Nyatepe-Coo E, et al. Prevalence of glaucoma in an African population. Eye (Lond) 2004;18:491-7.14. Nangia V, Jonas JB, Matin A, Bhojwani K, Sinha A, Kulkarni M, et al. Prevalence and associated factors of glaucoma in rural central India. The Central India Eye and Medical Study. PLoS One 2013;8:e76434.15. Neumann E, Zauberman H. Glaucoma survey in liberia. Am J Ophthalmol 1965;59:8-12.16. Wasim R, Shagufta R, Singh T. Profile of patients of glaucoma in Kashmir valley (A hospital based study). JK Sci 2010;12:137.17. FlorCruz NV, Joaquin‑Quino R, Silva PA, Khu PM. Profile of glaucoma cases seen at a tertiary referral hospital. Philipp J Ophthalmol 2005;30:161-5.18. Lichter PR, Musch DC, Gillespie BW, Guire KE, Janz NK, Wren PA, et al. Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery. Ophthalmology 2001;108:1943-53.19. Singh K, Shrivastava A. Medical management of glaucoma: Principles and practice. Indian J Ophthalmol 2011;59 Suppl: S88-92.20. Shen SY, Wong TY, Foster PJ, Loo JL, Rosman M, Loon SC, et al. The prevalence and types of glaucoma in Malay people: The Singapore Malay eye study. Invest Ophthalmol Vis Sci 2008;49:3846-51.21. Khandekarl R, Zutshi R. Glaucoma in oman: A review. J Glaucoma 2006;15:271-3.How to cite this article: Al Rashed AS, Al Subaie HA, Al Hathloul HS, Al Shehab KA, Al Naim MA, Kaliyadan KF, et al. Types of glaucoma in a University Health Centre in Al-Ahsa, Saudi Arabia: A pilot study. Niger J Ophthalmol 2015;23:12-5.Source of Support: Nil, Conflict of Interest: None declared

Types of glaucoma in a university health centre in Al‑Ahsa, Saudi Arabia: a pilot study

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Types of glaucoma in a university health centre in Al‑Ahsa, Saudi Arabia: a pilot study

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