Glaucoma is a disease with characteristic changes of the optic nerve, visual field and raised intra ocular pressure. Its prevalence varies between, 1.6 to 8% and is dependent on the ethnic composition of the population and it is one of the leading causes of blindness in the developed world. There are 67 800 000 people worldwide suffering from glaucoma.1 In recent years, a number of highly potent topical medications have been introduced. These have substantially improved the conservative management of glaucoma. New laser techniques are also being used and safer operative techniques have been developed in order to cope with the more resistant cases of glaucoma. A previous study on `Glaucoma in Malta', conducted in 1989, established that 3% of Maltese population over the age of 40 suffers from glaucoma.2 This study was carried out in order to assess the management of glaucoma patients in the Maltese Government Health Service at the present time.peer-reviewe

Francalanza, Martin

Janula, Jan

Mallia, Denis

English

OAR@UM

Malta Medical Journal    Volume 17   Issue 01   March 2005 33IntroductionGlaucoma is a disease with characteristic changes of theoptic nerve, visual field and raised intra ocular pressure. Itsprevalence varies between, 1.6 to 8% and is dependent on theethnic composition of the population and it is one of the leadingcauses of blindness in the developed world. There are  67 800000 people worldwide suffering from glaucoma.1In recent years, a number of highly potent topicalmedications have been introduced. These have substantiallyimproved the conservative management of glaucoma. New lasertechniques are also being used and safer operative techniqueshave been developed in order to cope with the more resistantcases of glaucoma.A previous study on ‘Glaucoma in Malta’, conducted in 1989,established that 3% of Maltese population over the age of 40suffers from glaucoma.2This study was carried out in order to assess themanagement of glaucoma patients in the Maltese GovernmentHealth Service at the present time.MethodsDuring the period from 1/7/2002 to 30/6/2003, a GlaucomaSurvey was carried out at St.Luke’s Hospital (SLH), GozoGeneral Hospital and in the five Health Centres in Malta.A specifically designed standard form was used by the doctors atthe outpatients department to record details of the visual functions(Snellen visual acuity and central visual field carried out by one ofauthors on Humphrey Visual Field Analyser), intraocular pressure,type of glaucoma and details of its management. Other sources used were Schedule V database (which recordspatients with chornic disease entitled to free medicines and themedication they are on), the Surgical Operations Register (SLH),Hospital Activity Analysis (SLH) and records of visual fieldexaminations. Collected data was analysed using an Excelspreadsheet and Access database.Management of Glaucomain the Maltese Health ServiceOriginal ArticleJan Janula, Denis Mallia, Martin FrancalanzaResultsBasic demographic data was collected for 2650 patients. Ofthese 1220 were women and 1430 were men, which give femaleto male ratio of 1:1.7 (Figure 1).Age distribution was examined (Figure 2), and clearlyGlaucoma in the Maltese population is exceptional below theage of 40, after which it starts to increase, reaching a peak atthe age of 75.Figure 1: Gender DistributionFigure 2:  Age DistributionJan Janula MD PhDDepartment of OphthalmologySt Luke’s Hospital, Guardamangia, MaltaEmail: jjanula161@onvol.netDenis Mallia MDDepartment of OphthalmologySt Luke’s Hospital, Guardamangia, MaltaMartin Francalanza MScDepartment of OphthalmologySt Luke’s Hospital, Guardamangia, Malta34 Malta Medical Journal    Volume 17   Issue 01   March 2005Detailed clinical data was collected for 874 glaucomapatients.  These were patients from two Consultants’ firms outof the five consultants treating ophthalmic patients in theGovernment Health Service.Figure 3 subdivides the 874 patients according the differentaeteological types of glaucoma. The majority of our patients(83.9%) suffer from Chronic Open Angle Glaucoma, 10.2% haveAcute or Chronic Angle Closure Glaucoma and 5.6 % suffer fromSecondary Glaucoma (mostly of the neovascular type) and theremaining (0.3%) suffer from Congenital Glaucoma. Cases ofLaser treatment was used in 6% of our patients; Nd YAGiridotomy was commonly performed in angle closure glaucoma:the number represents treatment of the eyes after an acute attackand fellow eyes. No laser iridotomy was performed on the patientwho had no previous acute glaucoma attack.  Argon lasertrabeculoplasty was performed on open angle glaucoma.The most common surgical intervention performed wastrabeculectomy which was used in 10% of cases. Noantimetabolite was ever used. The modern technique of non-perforating glaucoma surgery – viscocanaliculostomy - was usedin 1% of our cases, a procedure which was introduced in 2003at St Luke’s Hospital.Figure 3: Types of Glaucoma in Maltanormal tension glaucoma were included in the Open AngleGlaucoma group.Severity of the disease was assessed by the visual field loss(Figure 4). Of the total number of patients, 38% had no visualfield loss with a cup/disc ratio more then 0.4, 29% had minimalcentral visual field loss, 22% moderate and 8% had very severeFigure 4: Loss of Visual Fieldcentral visual field loss. Glaucoma was the reason of legalblindness in 3% of our patients.The different types of treatment were analysed and areshown in Figure 5. The majority of patients (83%) werecontrolled conservatively using mainly topical therapy.Figure 5: Different TherapiesWith regards to the topical therapy, the most commonlyused eye drops for glaucoma were beta-blockers. These areusually the first line of therapy. This is followed by dorsolamideand latanoprost. Long term systemic acetazolamide (Diamox)is still being used by a large number of patients (Figure 6).The majority of 2650 conservatively treated patients arecontrolled by one medication only, but there are 650 patientswho require three or more medications to achieve adequatecontrol (Figure 7).Figure 6: Use of different medicationsFigure 7: Number of medications per patientMalta Medical Journal    Volume 17   Issue 01   March 2005 35DiscussionIn the Maltese glaucoma population, there is a significantlyhigher number of males suffering from glaucoma than females.This is in agreement with other studies3,4,5  indicating that themale sex is another risk factor of glaucoma.Age distribution is very similar to other studies. The numberof glaucoma cases start to increase by the age of 40 and reachesa peak in the mid-seventies.5Open angle glaucoma usually represents the absolutemajority of glaucoma types in both Caucasian and blackpopulations. More than 50% of glaucoma sufferers in the Asianpopulation have angle closure glaucoma. Our study shows that90% of the Maltese glaucoma sufferers have of the open angletype.6,7,8Glaucoma is a potentially blinding disease. Its outcome isdependent on early diagnosis, efficient therapy and patientcompliance. There are 3.2% of glaucoma patients who are legallyblind. Most of them are cases of neovascular glaucoma.About 70% of our patients have minimal and 10% moderateloss of central visual field. A higher incidence of severe loss ofcentral visual field is prevented by the Glaucoma screeningprogram, which allows us to control the disease adequatelybefore advanced changes develop.As in other countries, the most common treatment ofglaucoma is based on topical eye drops, with beta blockers beingused as first preference. There are a relatively high number ofpeople using systemic acetazolamide, a treatment which isknown to have many side effects, especially in the elderly. Theuse of more than two topical medications is not very efficientand might be inconvenient to the patient. We suggest that weshould, in the future, be more rational in the use of dropscombinations.  In the UK there was a decline in glaucomasurgery owing to the introduction of very efficient moderntopical antiglaucoma medication.9  This is not reflected in Maltaas the number of glaucoma operations has remained steady overthe last 8 years (Table  9).  Furthermore, the use of laser in thetreatment of Glaucoma in Malta Health Service is low incomparison with other countries, the reason being locally thelack of modern laser devices required for this kind of treatment.ConclusionGlaucoma sufferers on the Maltese Islands have similarcharacteristic to glaucoma sufferers in other Europeancountries. A well conducted screening program allows us to treata high number of glaucoma patients before irreversible damageis done to the eye.Locally, glaucoma patients are well controlled.  However,in many cases, multiple  medications are used. A significantlylarger proportion of patients is using long term acetazolamide,which has undesirable side effects.It would be beneficial and cost-effective if new laserequipment were purchased so as to allow the use of transcleralcyclotherapy, selective trabeculoplasty and other techniques.Finally, we suggest that more frequent use of laser treatmentand more rational use of topical medication will improve careof glaucoma patients in Malta.References1. Klein BE, Klein R, Sponsel WE, Franke T, Cantor LB, Martone J,Menage MJ. Prevalence of glaucoma. The Beaver Dam Eye Study.Ophthalmology 1992 Oct;99(10):1499-504.2. Cachia J, Soler R, Blagojevic M, Agius Muscat H. Eye Disease –Survey, Malta, University of Malta, 19893. Tielsch JM, Katz J, Sommer A, Quigley HA, Javitt JC. Familyhistory and risk of primary open angle glaucoma. The BaltimoreEye Survey. Arch Ophthalmol 1994 Jan;112(1):69-73.4. Leske MC, Connell AMS, Wu S-Y, Hyman LG, Schachat AP (1995)The Barbados Eye Study Group: Risk factors for open-angleglaucoma Arch Ophthalmol, 113, 918-9245. Dielemans I, Vingerling JR, Wolfs RC, Hofman A, Grobbee DE, deJong PT. The prevalence of primary open-angle glaucoma in apopulation-based study in the Netherlands. The Rotterdam Study.Ophthalmology. 1999 Nov; 101 (11) :1851-5.6. Tielsch JM, Sommer A, Katz J, Royall RM, Quigley HA, Javitt J.Racial variations in the prevalence of primary open-angleglaucoma. The Baltimore Eye Survey. JAMA 1991 Jul17;266(3):369-74.7. Martin MJ, Sommer A, Gold EB, Diamond EL. Race and primaryopen-angle glaucoma. Am J Ophthalmol 1985 Apr 15;99(4):383-7.8. Shiose Y, Kitazawa Y, Tsukahara S, Akamatsu T, Mizokami K,Futa R, Katsushima H, Kosaki H.  Epidemiology of glaucoma inJapan—a nationwide glaucoma survey. Jpn JOphthalmol.1991;35(2):133-55.9. Bateman DN, Clark R, Azuara-Blanco A,†Bain CM, Forrest C .The impact of new drugs on management of glaucoma inScotland: observational study BMJ.†2001 December 15;†323(7326): 1401–1402.Figure 8: Number of Trabeculectomies

Azuara-Blanco A,†Bain CM, Forrest C . The impact of new drugs on management of glaucoma in

Epidemiology of glaucoma in Japan—a nationwide glaucoma survey.

Family history and risk of primary open angle glaucoma. The Baltimore Eye Survey. Arch Ophthalmol

Prevalence of glaucoma. The Beaver Dam Eye Study. Ophthalmology

Race and primary open-angle glaucoma.

Racial variations in the prevalence of primary open-angle glaucoma. The Baltimore Eye Survey. JAMA

The Barbados Eye Study Group: Risk factors for open-angle glaucoma Arch Ophthalmol,

The prevalence of primary open-angle glaucoma in a population-based study in the Netherlands. The Rotterdam Study. Ophthalmology.

Management of Glaucoma in the Maltese Health Service

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Management of Glaucoma in the Maltese Health Service

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