Profile of Newly Referred Glaucoma Patients to the Largest Tertiary Eye Care Hospital in Saudi Arabia

Profile of Newly Referred Glaucoma Patients to the Largest Tertiary Eye Care Hospital in Saudi Arabia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Profile of Newly Referred Glaucoma Patients to the Largest Tertiary Eye Care Hospital in Saudi Arabia Deema Jomar, Abdulrahman Alhomoud, Ibrahim AlObaida, Nasser AlSobaie, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2423328/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose : To report the profile of newly referred glaucoma patients to the largest tertiary eye care hospital in Saudi Arabia. Patients and Methods: Medical records of all Saudi nationals who presented with glaucoma to the Glaucoma Clinics at King Khaled Eye Specialist Hospital (KKESH) as a first visit through the Eligibility Department, Screening Clinic or Emergency Department between March 2019 and August 2019 were reviewed. Patients underwent a comprehensive glaucoma workup and a detailed documentation of their demographics, clinical exam findings, type and stage of glaucoma at presentation along with previous and offered management. Upon presentation, the stage of glaucoma was compared between eyes with primary glaucoma including primary open-angle glaucoma (POAG), primary angle-closure glaucoma (PACG) and eyes with Secondary glaucoma. Results: A total of 532 patients newly presented to KKESH during the study period. The median (interquartile [IQR] range) age of the patients was 63 (17) years, 47.9% of the patients were female. The majority of referred cases came from Riyadh (46.6%), Najran (9.8%) and AlQassim (9.4%) provinces. PACG was the most predominant form of glaucoma (30.5%), followed by POAG. Pseudoexfoliation glaucoma (PSXG) and neovascular glaucoma (NVG) were the most common subtypes among secondary glaucoma. Two out of every five eyes presenting with glaucoma (41.5%) had severe disease. Conclusion: In this tertiary setting, PACG was the most commonly encountered glaucoma. A significant proportion of the patients, particularly those with POAG (“the silent thief of sight”) presented with an advanced disease. To limit the irreversible visual loss and socio-economic burden of glaucoma, a large community-based study is required to look into the epidemiology of glaucoma among all Saudi provinces followed by the implementation of a national screening and intervention program. Epidemiology Glaucoma Saudi Arabia Primary angle-closure glaucoma Primary open-angle glaucoma pseudoexfoliation glaucoma neovascular glaucoma Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Glaucoma is a leading cause of irreversible blindness, and its various subtypes have remained a challenge to ophthalmologists worldwide. It is labeled as the second most common cause of blindness in patients aged 50 years and older in 2020 1 and its prevalence is estimated to rise affecting 111.8 million people in 2040. 2 Many factors such as the patient’s accessibility to medical facilities and compliance with treatment directly affect the overall disease outcome. Saudi Arabia (SA) is a geographically large country with modest ethnic and genetic heterogeneity 3 . Tabbara reported that glaucoma was responsible for blindness among 3% of the Saudi population above 40 years of age 4 . A study conducted in the northern region, reported that glaucoma was the least common cause of visual impairment with a prevalence of 5.8% in the study population. A more recent study conducted in Riyadh province (Except the capital), reported that glaucoma was prevalent in more than 1 in 20 Saudis aged 40 years and older 5 . As the prevalence of glaucoma types may differ from one region to another, community-based studies are crucial in understanding the diversity and distribution of the disease. Although few hospital-based studies were conducted to look into glaucoma characteristics and subtypes among Saudi population 6–10 , the prevalence of glaucoma in Saudi Arabia using community-based studies remains unknown. King Khaled Eye Specialist Hospital (KKESH) is the largest tertiary eye care hospital in Saudi Arabia catering for referrals from the majority of provinces across the kingdom. The aim of this study is to report the profile of newly referred glaucoma patients to KKESH. Knowing the demographic differences and patterns of glaucoma among different Saudi provinces, allows a better planning and allocation of glaucoma services and future community intervention. Materials And Methods Study design and ethical considerations This was a retrospective case series conducted at KKESH, Riyadh. The study was approved by the Institutional Review Board (IRB) of KKESH (IRB No. RP 2007-R) and adhered to the Declaration of Helsinki and followed the confidentiality requirements of the regional Privacy Act. Patient informed consent was waived by the IRB Committee due to the retrospective nature of the study. Hospital procedural codes were used to identify potential Saudi patients who presented to our institute for the first time with a confirmed diagnosis of glaucoma in one or both eyes over a period of 6 months (March 2019 - August 2019 inclusive). Glaucoma was defined as per International Society for Geographical and Epidemiologic Ophthalmology criteria (ISGEO) criteria 11 . Data Collection Patients’ electronic medical records were reviewed and data such as demographics, ophthalmic examination and ancillary test findings on initial evaluation including; uncorrected visual acuity, intraocular pressure measurement, gonioscopy findings, cup to disc ratio, central corneal thickness and visual field assessment using Humphrey or Goldmann perimetry were collected. The severity of glaucoma on presentation and initial management offered at our institute were also recorded. Severity of glaucoma was graded based on the criteria developed by the International Classification of Disease and Related Health Problems, 10th revision, which classifies glaucoma into mild, moderate and severe based on optic nerve and visual field abnormalities. 12 When determining the stage of glaucoma, eyes with unavailable visual field test or patients who are unreliable or incapable of performing a visual field test were analyzed as “indeterminate” stage as per ICD-10 classification. Inclusion and Exclusion Criteria All Saudi patients who were referred to our institute or presented through emergency room with a new diagnosis of glaucoma in one or both eyes during the study period were included in the current study. For monocular or unilateral glaucoma patients, phthisical, eviscerated or enucleated eyes in addition to healthy fellow eyes were excluded. Otherwise, for patients who had a bilateral diagnosis of glaucoma, both eyes were included and each eye was analyzed individually. Patients with multiple missing data or who were referred to glaucoma clinics from other sub-specialty service within the study institute were excluded from further analysis. Moreover, patients who did not meet the ISGEO criteria for diagnosing glaucoma by being labeled as “glaucoma suspect”, were also excluded. Data Analysis Data were entered in Microsoft Excel 2010 (Microsoft Corporation, Redmond, Washington) and analyzed using STATA 17.0 (StataCorp LLC, College Station, TX, USA). Both eyes were included in the analysis if both eyes were affected by glaucoma. Continuous data (age, IOP, AGM, and CCT) were described as mean with standard deviation (SD) or median with interquartile range(IQR), as appropriate. Categorical data (gender, laterality, disease severity, previous glaucoma surgery) were reported as frequencies and percentages. No inferential statistics were done. Results During the study period, a total of 982 patient’s records were identified and reviewed. After assessment for eligibility, 196 patients were found to be referred from other KKESH ophthalmic sub-specialty clinics, 190 patients had significantly insufficient data, and 64 patients were labeled as glaucoma suspect 13 thus excluded from the study. A total of 532 patients (906 eyes) fulfilled the inclusion criteria and were further analyzed. Among included patients, 127 eyes were fellow healthy eyes, and 31 eyes were either phthisical, eviscerated or enucleated thus excluded from the analysis. (Figure.1) The median (IQR) age of the patients was 63 (17) years. Two hundred and fifty-one (47.9%) were females and 277 (52.1%) males. (Table.1) The majority of referred cases were received from Riyadh province (46.6%), Najran (9.8%) and AlQassim (9.4%). (Figure.2). Table 1 Characteristics of study participants of most prevalent glaucoma subtypes. Characteristics Type of glaucoma* POAG PACG NVG PSXG Number of persons 122 162 66 76 Number of affected eyes 230 288 95 134 Gender Male 78 (63.9) 65 (40.1) 38 (57.6) 44 (57.9) Female 44 (36.1) 97 (59.9) 28 (42.4) 32 (42.1) Laterality Unilateral 14 (11.5) 36 (22.2) 37 (56.1) 18 (23.7) Bilateral 108 (88.5) 126 (77.8) 29 (43.9) 58 (76.3) Mean IOP, mmHg 16.96 ± 5.91 18.58 ± 8.14 27.52 ± 14.28 17.09 ± 6.98 Central Corneal Thickness, µm 531.57 ± 43.84 545.53 ± 47.24 570.26 ± 54.12 531.57 ± 44.82 Number of anti-glaucoma medication(s) 2.59 ± 1.22 2.91 ± 1.26 3.55 ± 0.96 2.77 ± 1.32 Previous glaucoma surgery Yes 9 (3.9) 12(4.2) 3 (3.2) 1 (0.7) No 221 (96.1) 276(95.8) 92 (96.8) 133 (99.3) *106 patients (159 eyes) had other types of glaucoma and were not included in this table. Upon evaluation of referral forms, 46% of the patients were referred with an unspecified diagnosis of glaucoma, 21% as primary open-angle glaucoma (POAG), and 13% as primary angle-closure glaucoma (PACG). Primary glaucoma accounted for approximately half of glaucoma cases in this study (284 out of 532). PACG was the most predominant type comprising 30.5% of the studied population, followed by POAG in (22.9%). Normal-tension glaucoma accounted for 0.9% of the cases. Among secondary glaucoma, pseudoexfoliation (PSXG) and neovascular glaucoma (NVG) were the two most common subtypes accounting for 14.3% and 12.4% of the cases, respectively. Other encountered types of secondary glaucoma included but not limited to lens induced (3.2%), uveitic (3.1%), traumatic (2.1%), steroid induced (0.9%), pigmentary (0.4%), and surgically induced glaucoma (0.2%). Childhood glaucoma accounted for 8% of the study population where 75% of them had primary congenital glaucoma (PCG). (Figure.3) Upon presentation, more than one-third of POAG patients (48.7%) presented with a severe stage of glaucoma in at least one eye, compared to (40.9%) of patients with PACG and (36%) of patients with secondary glaucoma. (Table.2) During the study duration of 6 months, (28%) of referred patients were booked for an urgent glaucoma surgery, including 45 deep sclerectomies, 35 trabeculectomies, 28 glaucoma drainage implants (GDD), and 30 procedures of cyclophotocoagulation. Table 2 Stage of glaucoma at presentation in eyes with primary and secondary glaucoma (n = 906 eyes). Stage POAG (n = 230 eyes) PACG (n = 288 eyes) NVG (n = 95 eyes) PSXG (n = 134 eyes) Other (n = 159 eyes) Freq % Freq % Freq % Freq % Freq % Mild 36 15.7 60 20.8 4 4.2 24 17.9 17 10.7 Moderate 59 25.7 42 14.6 7 7.4 27 20.1 18 11.3 Severe 114 49.6 139 48.3 24 25.3 64 47.8 35 22.0 Indeterminate 21 9.1 47 16.3 60 63.2 19 14.2 89 56.0 Further Analysis of Most Prevalent Glaucoma Subtypes PACG was the most prevalent type of glaucoma in this study and on further analysis, it was noted that the majority of PACG patients originated from Riyadh province (50%) followed by Qassim (13%), Najran (9%) and Makkah (7%). Among the 288 PACG eyes, acute angle-closure glaucoma (AACG) accounted for 192 eyes, and chronic angle-closure glaucoma (CACG) for 96 eyes. More than half of patients referred from Riyadh and Makkah underwent a laser peripheral iriditomy (LPI) at their primary institutes prior to presentation. In contrast, less than one-quarter of patients referred from Qassim (24%) and Najran (23%) had an LPI prior to presentation. Around one-third of PACG patients (40.9%) presented with a severe stage of glaucoma in one or either eye. POAG was the second most common subtype of glaucoma in this study where the majority of patients were referred from Riyadh province (54%) followed by Najran (13%). Around half of patients from both provinces had a severe stage of glaucoma in one or either eye at the time of presentation. Pseudoexfoliation Glaucoma was the most common subtype of secondary glaucoma. (49%) of patients were referred from Riyadh province, (21%) from Najran and (14%) from Aseer. Out of PSXG eyes, (63%) had an open angle on gonioscopy assessment, while (22%) had a closed angle. The median age at the time of presentation among adults’ glaucoma was highest for patients with PSXG (69 years) (Figure.4). Moreover, majority of referred patients (69%) were found to have a severe stage of glaucoma at the time of presentation. Neovascular Glaucoma was the second most common subtype of secondary glaucomas and out of those patients, (50%) were referred from Riyadh province, (15%) from Qassim, and (14%) from Aseer. Gonioscopy showed an open angle in (34%), closed angle in (31%) and it was not documented in (35%) of the studied eyes. Additionally, (24.2%) of referred patients presented with a severe stage of glaucoma, with majority being referred form Aseer province (60%). It is worth mentioning that in a considerable group of NVG patients, the stage of glaucoma could not be accurately assessed due to poor view at time of presentation, either due to a lens opacity or vitreous hemorrhage, which hindered the applicability of a visual field test. Discussion In this study, we aimed to look at the current profile of glaucoma in newly presenting patients to the largest tertiary eye care hospital in Saudi Arabia. It found that PACG was the most encountered subtype of glaucoma followed by POAG, PSXG and NVG. It also showed that a significant proportion of referred glaucoma patients, were found to have a severe stage of glaucoma at the time of presentation. The prevalence of glaucoma and its types worldwide vary significantly between different ethnicities and geography. 14 It was estimated that around 75–95% of glaucoma in the United States and Europe is secondary to POAG, in contrast to Asians and Eskimos, were PACG was found to be the predominant type. 15 A previous systematic review found that the overall prevalence of primary angle-closure in adult Asians was 0.75%, with a prevalence rate of 0.97% among the Middle Eastern population, 0.66% in southeast Asians, 0.46% in Indians, 1.10% in Chinese individuals, and 1.19% in the Japanese population. 16 A higher tendency to have shallower anterior chamber depths in Asians 17 was proposed as the reason behind the higher rates of PACG. 18 However, this remains uncertain as conflicting results present; where other studies reported no clear-cut biometric differences between Asians and other populations. 19 Few studies were conducted on populations with Middle Eastern descent, which reported a higher prevalence of POAG followed by both PACG and PSXG. 20,21 In the Gulf region, two community-based studies were carried out in Oman and Qatar, which reported POAG as the most prevalent type, followed by PACG. 22,23 Our study revealed that the most common subtype of glaucoma was PACG, and this was in line with two other hospital-based studies that were conducted in Riyadh 7 and Qassim 10 provinces. On the contrary, other studies carried out in the western 9,24 and eastern 6 regions of Saudi Arabia, reported the dominance of POAG over other glaucoma subtypes. The variation in the reported results by Eid et al. was attributed to having a multiethnic population in the western region, where a considerable number of patients were from other communities which may have resulted in a racial heterogeneity in the study population. 9 Contrary to this, we estimate a minimal heterogeneity and variation of ethnicity in our population, which makes it comparable to the studied population of AlObeidan et al and Alzuhairy et al. 7,25 Further analysis of cases with secondary glaucoma revealed that PSXG and NVG were the most two common subtypes comprising around two-thirds of secondary glaucoma cases. This finding ties well with other local studies which reported identical results. 6,7,10 Pseudoexfoliation syndrome (PXS) and glaucoma are highly prevalent in Scandinavian, 26 Arabic 27,28 and Mediterranean 29,30 populations. Several previous studies reported that women may experience PXF at higher rates than men, 31,32 while others showed no significant gender differences. 29,33,34 Conversely, few regional studies reported a higher male predominance of disease; 28,35,36 and this was consistent with our study, which showed a male-to-female ratio of (58%/42%). Bilateral glaucoma was noted in (35%) of PSXG patients, and upon gonioscopy evaluation, (63%) had open-angle glaucoma while 22% had a closed angle (15% did not have a documented gonioscopy exam). This rate of closed-angle glaucoma secondary to PSX was similar to a study by Owaifeer et al, who reported that (25.1%) had narrow angles, 37 higher than what was reported by Al-Saleh et al (11.5%), 34 and lower than what was published by AlObeidan et al who reported that more than two thirds of Saudi PSXG patients had a closed angle. 7 Diabetes mellitus (DM) is a major comorbidity in the adult Saudi population, 38 and it was found to be the primary cause of NVG in Saudi Arabia. 39,40 During the past ten years, the overall annual incidence of NVG in Saudi Arabia was estimated to be 6.6/100,000 (0.07%), with a dramatic decrease following the introduction of anti-VEGF therapy. 40 NVG comprised around one-third of the total cases of secondary glaucoma in this study (95 eyes), where one-third (34%) were found to have open-angle glaucoma, while (31%) had closed angles (35% did not have a documented gonioscopy exam). Majority of cases presented to the Emergency room of our ophthalmic center and received the required acute treatment in a timely manner. Noteworthy, the rate of NVG in some previous local studies were lower than ours. 6,7,9 Eid et al found that more than 90% of NVG patients in the western region had closed-angle glaucoma. 9 This may indicate that a good proportion of our NVG patients were somehow referred at an earlier stage, where the angle was still salvageable. This may be explained by the nature of the disease being associated with proliferative diabetic retinopathy in the majority of cases, resulting in early visual symptoms that at least will prompt a patient to seek ophthalmic care in an emergency room at an earlier stage, allowing an early detection by gonioscopy exam and prompt management. As diabetic retinopathy and associated NVG are known to have a high morbidity, and it is of particular concern to ophthalmologists in our country, implementing preventative strategies to decrease the prevalence and spread awareness about DM and its associated complications is crucial. The study’s institute has a reasonably tight eligibility criteria as a tertiary referral center, where only patients with advanced glaucoma in at least one eye or refractory glaucoma to maximum medical treatment were eligible for treatment. This may explain the large proportion of patients who had a severe glaucoma in at least one eye (37.7%) upon presentation; however, it may also reflect that a sizable number of the Saudi population are unaware of their disease. A recent study published by AlNajmi et al, studied the rate of legal blindness from glaucoma among 248 patients in a tertiary referral center in Riyadh (King Abdulaziz Medical City) and reported that nearly onequarter (26.6%; n = 66) of the included patients (248 patients) were legally blind, out of those, 71.2% had either eye affected, and 28.8% had both eyes affected. 41 This can be further explained by the lack of awareness and efficient screening programs in rural areas which resulted in a delayed presentation to eye care providers. Moreover, the scarcity or limited use of glaucoma diagnosing equipment in the referring secondary or tertiary centers might be another factor which leads to underestimating the actual stage of glaucoma and late referral of patients to higher ophthalmic centers when needed. Lastly, it is worth discussing that patients with POAG presented at a more advanced stage (48.7%) than PACG (40.9%), which is attributed to the greater likelihood of patients with PACG and some secondary glaucoma; as neovascular, uveitic or lens-induced glaucoma to be symptomatic, which results in seeking medical attention earlier than POAG patients. The findings of our study must be carefully interpreted given the retrospective nature of the study and the possibility of it being subjected to potential selection bias due to the referral nature of patients and the presence of an eligibility criteria. It was also subjected to information bias where the data collection process was limited by variable recording of patient’s information by multiple physicians. However, we accounted for this by excluding all cases who had significantly insufficient or missing data. Despite these limitations, our study is one of the first studies to look at the profile of newly referred glaucoma patients at the largest tertiary eye care center in Saudi Arabia, and adds valuable information to the literature. The collected data helps better understand the demographic differences and patterns of glaucoma in Saudi Arabia, and is expected to work as a future database, providing helpful background information for a series of national community-based epidemiological studies. Once again, this study is not considered a representative sample of the Saudi population but rather a description of a hospital-based population in the largest tertiary referral center in Saudi Arabia. Community-based studies are required for a better allocation and delivery of an efficient eye care system, and perhaps providing hospital-based data from semi-urban places may be of great value in complementing the final picture of a large community-based study. This study also confirms the need for a national screening and intervention program to help early detection and referral of glaucoma cases to prevent late presentation with advanced stages. Declarations Ethics approval and consent to participate : The study was approved by the Institutional Review Board (IRB) of KKESH (IRB No. RP 2007-R) and adhered to the Declaration of Helsinki and followed the confidentiality requirements of the regional Privacy Act. Patient informed consent was waived by the IRB Committee due to the retrospective nature of the study. Consent for publication : Not applicable. Availability of data and materials : The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests : All authors reports no conflicts of interest in this work. Funding : None Authors' contributions : Deema E. Jomar: Literature Review, Resources, Investigation, Writing- Original draft-preparation Abdulrahman Alhomoud: Designing Data Collection form, Data Collection, Resources Ibrahim AlObaida: Writing- Reviewing and Editing, Resources Nasser AlSobaie: Data Collection, Resources Hala Helmi: Data Collection, Resources Khabir Ahmad: Data Analysis , Designing Figures, Writing- Reviewing and Editing Ohoud Owaidhah: Writing- Reviewing and Editing Konrad Schargel: Conceptualization, Project administration, Writing- Reviewing and Editing Acknowledgements : Thanks to Ms. Samia Timbol “Coder/Analyst” at King Khaled Eye Specialist Hospital for her great assistance in the acquisition of data needed for this project. References Bourne RRA, Steinmetz JD, Saylan M, et al. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: The Right to Sight: An analysis for the Global Burden of Disease Study. 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Prevalence of pseudoexfoliation syndrome and pseudoexfoliation glaucoma in Upper Egypt. BMC Ophthalmol . 2011;11(1). doi:10.1186/1471-2415-11-18 Gur Gungor S. The Characteristics of Pseudoexfoliation Glaucoma in Ankara, the Capital of Turkey. Eur Eye Res . 2021;1(1):6–12. doi:10.14744/eer.2021.88597 Owaifeer A, Mohammed A, AlObaida I, et al. Frequency and risk factors of narrow angles in patients with pseudoexfoliation: a case–control study. Int Ophthalmol . Published online 2021:1–7. Al-Daghri NM, Al-Attas OS, Alokail MS, et al. Diabetes mellitus type 2 and other chronic non-communicable diseases in the central region, Saudi Arabia (riyadh cohort 2): A decade of an epidemic. BMC Med . 2011;9(1):76. doi:10.1186/1741-7015-9-76 Al-Shamsi H, Dueker D, Nowilaty S, Al-Shahwan S. Neovascular glaucoma at King Khaled Eye Specialist Hospital - etiologic considerations. Middle East Afr J Ophthalmol . 2009;16(1):15. doi:10.4103/0974-9233.48860 Al-Bahlal A, Khandekar R, Al Rubaie K, Alzahim T, Edward DP, Kozak I. Changing epidemiology of neovascular glaucoma from 2002 to 2012 at King Khaled Eye Specialist Hospital, Saudi Arabia. Indian J Ophthalmol . 2017;65(10):969–973. doi:10.4103/ijo.IJO_33_17 Al-Najmi Y, Kirat O, Abdalla Elsayed MEA, Albeedh M, Al-Rashed D, Al-Mohammed A. Glaucoma Diagnoses and Legal Blindness from Glaucoma among Bedouin Patients of Central Saudi Arabia: A Hospital-Based Study. Middle East Afr J Ophthalmol . 2021;28(1):29–35. doi:10.4103/meajo.MEAJO_77_21 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2423328","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":164229216,"identity":"4b236fb3-144b-4c3b-a7f0-92a390d89306","order_by":0,"name":"Deema Jomar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIie3RIQvCQBTA8bdiGq6+odOvMBmcZfhZHIOlC36ES64IVj+Gacnw5NAV0epYMc1i0CgIuonBdNMmeP/wuIP7cRwHoNP9YkTV9F0EaFQrQ3xIoq/Ic8ovSHMpV/PrYufZcVwcDO47wpIHJbFpHWWTImctc9N3jSTyBEaukri0YXuTcr+DvIFGIgOBUE+yG239TvdYlOQeCCs915LcJGItBFYSCgRw9S3VW/I2hZ494QyDJPTGyEdK0tzLdXaiQW+WpgVekoEztdK5kgDS22YIr99RZonaIzqdTvfvPQBL7E/WLLK18wAAAABJRU5ErkJggg==","orcid":"","institution":"King Khaled Eye Specialist Hospital","correspondingAuthor":true,"prefix":"","firstName":"Deema","middleName":"","lastName":"Jomar","suffix":""},{"id":164229217,"identity":"5f4de6e7-77ae-4f49-82aa-ed1752e424a1","order_by":1,"name":"Abdulrahman Alhomoud","email":"","orcid":"","institution":"King Khaled Eye Specialist Hospital","correspondingAuthor":false,"prefix":"","firstName":"Abdulrahman","middleName":"","lastName":"Alhomoud","suffix":""},{"id":164229218,"identity":"cc76b325-0766-4b95-98bf-ae7042166a68","order_by":2,"name":"Ibrahim AlObaida","email":"","orcid":"","institution":"King Khaled Eye Specialist Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ibrahim","middleName":"","lastName":"AlObaida","suffix":""},{"id":164229219,"identity":"5abdc8dd-1385-4344-bc1e-97913efe797c","order_by":3,"name":"Nasser AlSobaie","email":"","orcid":"","institution":"King Khaled Eye Specialist Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nasser","middleName":"","lastName":"AlSobaie","suffix":""},{"id":164229220,"identity":"47333bf0-7523-4e66-9b2f-e6c201a829c8","order_by":4,"name":"Hala Helmi","email":"","orcid":"","institution":"King Faisal Specialist Hospital and Research Center","correspondingAuthor":false,"prefix":"","firstName":"Hala","middleName":"","lastName":"Helmi","suffix":""},{"id":164229221,"identity":"5adc5341-96a8-4347-a865-05b16db2060d","order_by":5,"name":"Khabir Ahmad","email":"","orcid":"","institution":"King Khaled Eye Specialist Hospital","correspondingAuthor":false,"prefix":"","firstName":"Khabir","middleName":"","lastName":"Ahmad","suffix":""},{"id":164229222,"identity":"e5a5f8f0-d5a6-4532-8657-2b2f73a7a024","order_by":6,"name":"Ohoud Owaidhah","email":"","orcid":"","institution":"King Khaled Eye Specialist Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ohoud","middleName":"","lastName":"Owaidhah","suffix":""},{"id":164229223,"identity":"6262d0ac-0cf4-4aa9-9f78-9504f6ed1ecd","order_by":7,"name":"Konrad Schargel","email":"","orcid":"","institution":"King Khaled Eye Specialist Hospital","correspondingAuthor":false,"prefix":"","firstName":"Konrad","middleName":"","lastName":"Schargel","suffix":""}],"badges":[],"createdAt":"2022-12-28 20:59:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2423328/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2423328/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":31178714,"identity":"def0ae31-88c8-4e55-8430-af8271c25641","added_by":"auto","created_at":"2023-01-05 18:22:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":66583,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of the\u003c/strong\u003e \u003cstrong\u003ereferring Saudi province among the study patient.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2423328/v1/5e01412d6479a11b05166aca.png"},{"id":31179519,"identity":"2cbcdba1-cd9d-454d-9b30-6959692b42d2","added_by":"auto","created_at":"2023-01-05 18:30:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":867010,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of glaucoma patients by prevalence of each subtype.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-2423328/v1/2d3a0ffc074da817cf9c84b9.png"},{"id":31178716,"identity":"cbefd0cf-6e2a-40f4-b34c-d3dad40d5859","added_by":"auto","created_at":"2023-01-05 18:22:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":46557,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMedian Age at presentation of different glaucoma subtypes\u003c/strong\u003e.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-2423328/v1/42aa410176586f0975597477.png"},{"id":31179893,"identity":"196e5bc9-07ce-4ff6-beca-15453ca75dae","added_by":"auto","created_at":"2023-01-05 18:38:25","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":80577,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of glaucoma subtypes by age (years).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e* Include childhood glaucoma and other sub-types of secondary glaucoma\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-2423328/v1/98fea42129382d378d02e450.png"},{"id":31195270,"identity":"57931bf2-d535-448c-97e3-00e47cbccb3b","added_by":"auto","created_at":"2023-01-06 04:29:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1120587,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2423328/v1/0852daba-b70d-4447-bf66-7335381a3061.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Profile of Newly Referred Glaucoma Patients to the Largest Tertiary Eye Care Hospital in Saudi Arabia","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGlaucoma is a leading cause of irreversible blindness, and its various subtypes have remained a challenge to ophthalmologists worldwide. It is labeled as the second most common cause of blindness in patients aged 50 years and older in 2020 \u003csup\u003e1\u003c/sup\u003e and its prevalence is estimated to rise affecting 111.8\u0026nbsp;million people in 2040. \u003csup\u003e2\u003c/sup\u003e Many factors such as the patient\u0026rsquo;s accessibility to medical facilities and compliance with treatment directly affect the overall disease outcome.\u003c/p\u003e \u003cp\u003eSaudi Arabia (SA) is a geographically large country with modest ethnic and genetic heterogeneity \u003csup\u003e3\u003c/sup\u003e. Tabbara reported that glaucoma was responsible for blindness among 3% of the Saudi population above 40 years of age \u003csup\u003e4\u003c/sup\u003e. A study conducted in the northern region, reported that glaucoma was the least common cause of visual impairment with a prevalence of 5.8% in the study population. A more recent study conducted in Riyadh province (Except the capital), reported that glaucoma was prevalent in more than 1 in 20 Saudis aged 40 years and older \u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAs the prevalence of glaucoma types may differ from one region to another, community-based studies are crucial in understanding the diversity and distribution of the disease. Although few hospital-based studies were conducted to look into glaucoma characteristics and subtypes among Saudi population \u003csup\u003e6\u0026ndash;10\u003c/sup\u003e, the prevalence of glaucoma in Saudi Arabia using community-based studies remains unknown.\u003c/p\u003e \u003cp\u003eKing Khaled Eye Specialist Hospital (KKESH) is the largest tertiary eye care hospital in Saudi Arabia catering for referrals from the majority of provinces across the kingdom. The aim of this study is to report the profile of newly referred glaucoma patients to KKESH. Knowing the demographic differences and patterns of glaucoma among different Saudi provinces, allows a better planning and allocation of glaucoma services and future community intervention.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and ethical considerations\u003c/h2\u003e \u003cp\u003eThis was a retrospective case series conducted at KKESH, Riyadh. The study was approved by the Institutional Review Board (IRB) of KKESH (IRB No. RP 2007-R) and adhered to the Declaration of Helsinki and followed the confidentiality requirements of the regional Privacy Act. Patient informed consent was waived by the IRB Committee due to the retrospective nature of the study. Hospital procedural codes were used to identify potential Saudi patients who presented to our institute for the first time with a confirmed diagnosis of glaucoma in one or both eyes over a period of 6 months (March 2019 - August 2019 inclusive). Glaucoma was defined as per International Society for Geographical and Epidemiologic Ophthalmology criteria (ISGEO) criteria \u003csup\u003e11\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003ePatients\u0026rsquo; electronic medical records were reviewed and data such as demographics, ophthalmic examination and ancillary test findings on initial evaluation including; uncorrected visual acuity, intraocular pressure measurement, gonioscopy findings, cup to disc ratio, central corneal thickness and visual field assessment using Humphrey or Goldmann perimetry were collected.\u003c/p\u003e \u003cp\u003eThe severity of glaucoma on presentation and initial management offered at our institute were also recorded. Severity of glaucoma was graded based on the criteria developed by the International Classification of Disease and Related Health Problems, 10th revision, which classifies glaucoma into mild, moderate and severe based on optic nerve and visual field abnormalities.\u003csup\u003e12\u003c/sup\u003e When determining the stage of glaucoma, eyes with unavailable visual field test or patients who are unreliable or incapable of performing a visual field test were analyzed as \u0026ldquo;indeterminate\u0026rdquo; stage as per ICD-10 classification.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003eAll Saudi patients who were referred to our institute or presented through emergency room with a new diagnosis of glaucoma in one or both eyes during the study period were included in the current study. For monocular or unilateral glaucoma patients, phthisical, eviscerated or enucleated eyes in addition to healthy fellow eyes were excluded. Otherwise, for patients who had a bilateral diagnosis of glaucoma, both eyes were included and each eye was analyzed individually. Patients with multiple missing data or who were referred to glaucoma clinics from other sub-specialty service within the study institute were excluded from further analysis. Moreover, patients who did not meet the ISGEO criteria for diagnosing glaucoma by being labeled as \u0026ldquo;glaucoma suspect\u0026rdquo;, were also excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData were entered in Microsoft Excel 2010 (Microsoft Corporation, Redmond, Washington) and analyzed using STATA 17.0 (StataCorp LLC, College Station, TX, USA). Both eyes were included in the analysis if both eyes were affected by glaucoma. Continuous data (age, IOP, AGM, and CCT) were described as mean with standard deviation (SD) or median with interquartile range(IQR), as appropriate. Categorical data (gender, laterality, disease severity, previous glaucoma surgery) were reported as frequencies and percentages. No inferential statistics were done.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the study period, a total of 982 patient\u0026rsquo;s records were identified and reviewed. After assessment for eligibility, 196 patients were found to be referred from other KKESH ophthalmic sub-specialty clinics, 190 patients had significantly insufficient data, and 64 patients were labeled as glaucoma suspect \u003csup\u003e13\u003c/sup\u003e thus excluded from the study. A total of 532 patients (906 eyes) fulfilled the inclusion criteria and were further analyzed. Among included patients, 127 eyes were fellow healthy eyes, and 31 eyes were either phthisical, eviscerated or enucleated thus excluded from the analysis. (Figure.1)\u003c/p\u003e \u003cp\u003eThe median (IQR) age of the patients was 63 (17) years. Two hundred and fifty-one (47.9%) were females and 277 (52.1%) males. (Table.1) The majority of referred cases were received from Riyadh province (46.6%), Najran (9.8%) and AlQassim (9.4%). (Figure.2).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eCharacteristics of study participants of most prevalent glaucoma subtypes.\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eType of glaucoma*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePOAG\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePACG\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNVG\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePSXG\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of persons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of affected eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e134\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (63.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (40.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (57.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44 (57.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (36.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97 (59.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (42.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32 (42.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaterality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (56.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (23.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e108 (88.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e126 (77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (43.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58 (76.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean IOP, mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.96\u0026thinsp;\u0026plusmn;\u0026thinsp;5.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.58\u0026thinsp;\u0026plusmn;\u0026thinsp;8.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.52\u0026thinsp;\u0026plusmn;\u0026thinsp;14.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.09\u0026thinsp;\u0026plusmn;\u0026thinsp;6.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCentral Corneal Thickness, \u0026micro;m\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e531.57\u0026thinsp;\u0026plusmn;\u0026thinsp;43.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e545.53\u0026thinsp;\u0026plusmn;\u0026thinsp;47.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e570.26\u0026thinsp;\u0026plusmn;\u0026thinsp;54.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e531.57\u0026thinsp;\u0026plusmn;\u0026thinsp;44.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of anti-glaucoma medication(s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.59\u0026thinsp;\u0026plusmn;\u0026thinsp;1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.91\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious glaucoma surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e221 (96.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e276(95.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92 (96.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e133 (99.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*106 patients (159 eyes) had other types of glaucoma and were not included in this table.\u003c/p\u003e \u003cp\u003eUpon evaluation of referral forms, 46% of the patients were referred with an unspecified diagnosis of glaucoma, 21% as primary open-angle glaucoma (POAG), and 13% as primary angle-closure glaucoma (PACG).\u003c/p\u003e \u003cp\u003ePrimary glaucoma accounted for approximately half of glaucoma cases in this study (284 out of 532). PACG was the most predominant type comprising 30.5% of the studied population, followed by POAG in (22.9%). Normal-tension glaucoma accounted for 0.9% of the cases. Among secondary glaucoma, pseudoexfoliation (PSXG) and neovascular glaucoma (NVG) were the two most common subtypes accounting for 14.3% and 12.4% of the cases, respectively. Other encountered types of secondary glaucoma included but not limited to lens induced (3.2%), uveitic (3.1%), traumatic (2.1%), steroid induced (0.9%), pigmentary (0.4%), and surgically induced glaucoma (0.2%). Childhood glaucoma accounted for 8% of the study population where 75% of them had primary congenital glaucoma (PCG). (Figure.3)\u003c/p\u003e \u003cp\u003eUpon presentation, more than one-third of POAG patients (48.7%) presented with a severe stage of glaucoma in at least one eye, compared to (40.9%) of patients with PACG and (36%) of patients with secondary glaucoma. (Table.2) During the study duration of 6 months, (28%) of referred patients were booked for an urgent glaucoma surgery, including 45 deep sclerectomies, 35 trabeculectomies, 28 glaucoma drainage implants (GDD), and 30 procedures of cyclophotocoagulation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eStage of glaucoma at presentation in eyes with primary and secondary glaucoma (n\u0026thinsp;=\u0026thinsp;906 eyes).\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePOAG\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;230 eyes)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003ePACG\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;288 eyes)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eNVG\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;95 eyes)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003ePSXG\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;134 eyes)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;159 eyes)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFreq\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFreq\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFreq\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFreq\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eFreq\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e17.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e20.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e11.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e48.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e25.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e47.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e22.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndeterminate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e63.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e14.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e56.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFurther Analysis of Most Prevalent Glaucoma Subtypes\u003c/h2\u003e \u003cp\u003ePACG was the most prevalent type of glaucoma in this study and on further analysis, it was noted that the majority of PACG patients originated from Riyadh province (50%) followed by Qassim (13%), Najran (9%) and Makkah (7%).\u003c/p\u003e \u003cp\u003eAmong the 288 PACG eyes, acute angle-closure glaucoma (AACG) accounted for 192 eyes, and chronic angle-closure glaucoma (CACG) for 96 eyes. More than half of patients referred from Riyadh and Makkah underwent a laser peripheral iriditomy (LPI) at their primary institutes prior to presentation. In contrast, less than one-quarter of patients referred from Qassim (24%) and Najran (23%) had an LPI prior to presentation. Around one-third of PACG patients (40.9%) presented with a severe stage of glaucoma in one or either eye.\u003c/p\u003e \u003cp\u003ePOAG was the second most common subtype of glaucoma in this study where the majority of patients were referred from Riyadh province (54%) followed by Najran (13%). Around half of patients from both provinces had a severe stage of glaucoma in one or either eye at the time of presentation.\u003c/p\u003e \u003cp\u003ePseudoexfoliation Glaucoma was the most common subtype of secondary glaucoma. (49%) of patients were referred from Riyadh province, (21%) from Najran and (14%) from Aseer. Out of PSXG eyes, (63%) had an open angle on gonioscopy assessment, while (22%) had a closed angle. The median age at the time of presentation among adults\u0026rsquo; glaucoma was highest for patients with PSXG (69 years) (Figure.4). Moreover, majority of referred patients (69%) were found to have a severe stage of glaucoma at the time of presentation.\u003c/p\u003e \u003cp\u003eNeovascular Glaucoma was the second most common subtype of secondary glaucomas and out of those patients, (50%) were referred from Riyadh province, (15%) from Qassim, and (14%) from Aseer. Gonioscopy showed an open angle in (34%), closed angle in (31%) and it was not documented in (35%) of the studied eyes. Additionally, (24.2%) of referred patients presented with a severe stage of glaucoma, with majority being referred form Aseer province (60%). It is worth mentioning that in a considerable group of NVG patients, the stage of glaucoma could not be accurately assessed due to poor view at time of presentation, either due to a lens opacity or vitreous hemorrhage, which hindered the applicability of a visual field test.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we aimed to look at the current profile of glaucoma in newly presenting patients to the largest tertiary eye care hospital in Saudi Arabia. It found that PACG was the most encountered subtype of glaucoma followed by POAG, PSXG and NVG. It also showed that a significant proportion of referred glaucoma patients, were found to have a severe stage of glaucoma at the time of presentation.\u003c/p\u003e \u003cp\u003eThe prevalence of glaucoma and its types worldwide vary significantly between different ethnicities and geography. \u003csup\u003e14\u003c/sup\u003e It was estimated that around 75\u0026ndash;95% of glaucoma in the United States and Europe is secondary to POAG, in contrast to Asians and Eskimos, were PACG was found to be the predominant type. \u003csup\u003e15\u003c/sup\u003e A previous systematic review found that the overall prevalence of primary angle-closure in adult Asians was 0.75%, with a prevalence rate of 0.97% among the Middle Eastern population, 0.66% in southeast Asians, 0.46% in Indians, 1.10% in Chinese individuals, and 1.19% in the Japanese population. \u003csup\u003e16\u003c/sup\u003e A higher tendency to have shallower anterior chamber depths in Asians \u003csup\u003e17\u003c/sup\u003ewas proposed as the reason behind the higher rates of PACG.\u003csup\u003e18\u003c/sup\u003e However, this remains uncertain as conflicting results present; where other studies reported no clear-cut biometric differences between Asians and other populations. \u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFew studies were conducted on populations with Middle Eastern descent, which reported a higher prevalence of POAG followed by both PACG and PSXG. \u003csup\u003e20,21\u003c/sup\u003e In the Gulf region, two community-based studies were carried out in Oman and Qatar, which reported POAG as the most prevalent type, followed by PACG. \u003csup\u003e22,23\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOur study revealed that the most common subtype of glaucoma was PACG, and this was in line with two other hospital-based studies that were conducted in Riyadh \u003csup\u003e7\u003c/sup\u003e and Qassim \u003csup\u003e10\u003c/sup\u003e provinces. On the contrary, other studies carried out in the western \u003csup\u003e9,24\u003c/sup\u003e and eastern \u003csup\u003e6\u003c/sup\u003e regions of Saudi Arabia, reported the dominance of POAG over other glaucoma subtypes. The variation in the reported results by Eid et al. was attributed to having a multiethnic population in the western region, where a considerable number of patients were from other communities which may have resulted in a racial heterogeneity in the study population. \u003csup\u003e9\u003c/sup\u003e Contrary to this, we estimate a minimal heterogeneity and variation of ethnicity in our population, which makes it comparable to the studied population of AlObeidan et al and Alzuhairy et al. \u003csup\u003e7,25\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFurther analysis of cases with secondary glaucoma revealed that PSXG and NVG were the most two common subtypes comprising around two-thirds of secondary glaucoma cases. This finding ties well with other local studies which reported identical results. \u003csup\u003e6,7,10\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePseudoexfoliation syndrome (PXS) and glaucoma are highly prevalent in Scandinavian, \u003csup\u003e26\u003c/sup\u003e Arabic \u003csup\u003e27,28\u003c/sup\u003e and Mediterranean \u003csup\u003e29,30\u003c/sup\u003e populations. Several previous studies reported that women may experience PXF at higher rates than men, \u003csup\u003e31,32\u003c/sup\u003e while others showed no significant gender differences. \u003csup\u003e29,33,34\u003c/sup\u003e Conversely, few regional studies reported a higher male predominance of disease; \u003csup\u003e28,35,36\u003c/sup\u003e and this was consistent with our study, which showed a male-to-female ratio of (58%/42%). Bilateral glaucoma was noted in (35%) of PSXG patients, and upon gonioscopy evaluation, (63%) had open-angle glaucoma while 22% had a closed angle (15% did not have a documented gonioscopy exam). This rate of closed-angle glaucoma secondary to PSX was similar to a study by Owaifeer et al, who reported that (25.1%) had narrow angles,\u003csup\u003e37\u003c/sup\u003e higher than what was reported by Al-Saleh et al (11.5%), \u003csup\u003e34\u003c/sup\u003e and lower than what was published by AlObeidan et al who reported that more than two thirds of Saudi PSXG patients had a closed angle. \u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDiabetes mellitus (DM) is a major comorbidity in the adult Saudi population, \u003csup\u003e38\u003c/sup\u003e and it was found to be the primary cause of NVG in Saudi Arabia.\u003csup\u003e39,40\u003c/sup\u003e During the past ten years, the overall annual incidence of NVG in Saudi Arabia was estimated to be 6.6/100,000 (0.07%), with a dramatic decrease following the introduction of anti-VEGF therapy.\u003csup\u003e40\u003c/sup\u003e NVG comprised around one-third of the total cases of secondary glaucoma in this study (95 eyes), where one-third (34%) were found to have open-angle glaucoma, while (31%) had closed angles (35% did not have a documented gonioscopy exam). Majority of cases presented to the Emergency room of our ophthalmic center and received the required acute treatment in a timely manner.\u003c/p\u003e \u003cp\u003e Noteworthy, the rate of NVG in some previous local studies were lower than ours. \u003csup\u003e6,7,9\u003c/sup\u003e Eid et al found that more than 90% of NVG patients in the western region had closed-angle glaucoma.\u003csup\u003e9\u003c/sup\u003e This may indicate that a good proportion of our NVG patients were somehow referred at an earlier stage, where the angle was still salvageable. This may be explained by the nature of the disease being associated with proliferative diabetic retinopathy in the majority of cases, resulting in early visual symptoms that at least will prompt a patient to seek ophthalmic care in an emergency room at an earlier stage, allowing an early detection by gonioscopy exam and prompt management. As diabetic retinopathy and associated NVG are known to have a high morbidity, and it is of particular concern to ophthalmologists in our country, implementing preventative strategies to decrease the prevalence and spread awareness about DM and its associated complications is crucial.\u003c/p\u003e \u003cp\u003eThe study\u0026rsquo;s institute has a reasonably tight eligibility criteria as a tertiary referral center, where only patients with advanced glaucoma in at least one eye or refractory glaucoma to maximum medical treatment were eligible for treatment. This may explain the large proportion of patients who had a severe glaucoma in at least one eye (37.7%) upon presentation; however, it may also reflect that a sizable number of the Saudi population are unaware of their disease. A recent study published by AlNajmi et al, studied the rate of legal blindness from glaucoma among 248 patients in a tertiary referral center in Riyadh (King Abdulaziz Medical City) and reported that nearly onequarter (26.6%; n\u0026thinsp;=\u0026thinsp;66) of the included patients (248 patients) were legally blind, out of those, 71.2% had either eye affected, and 28.8% had both eyes affected.\u003csup\u003e41\u003c/sup\u003e This can be further explained by the lack of awareness and efficient screening programs in rural areas which resulted in a delayed presentation to eye care providers. Moreover, the scarcity or limited use of glaucoma diagnosing equipment in the referring secondary or tertiary centers might be another factor which leads to underestimating the actual stage of glaucoma and late referral of patients to higher ophthalmic centers when needed. Lastly, it is worth discussing that patients with POAG presented at a more advanced stage (48.7%) than PACG (40.9%), which is attributed to the greater likelihood of patients with PACG and some secondary glaucoma; as neovascular, uveitic or lens-induced glaucoma to be symptomatic, which results in seeking medical attention earlier than POAG patients.\u003c/p\u003e \u003cp\u003eThe findings of our study must be carefully interpreted given the retrospective nature of the study and the possibility of it being subjected to potential selection bias due to the referral nature of patients and the presence of an eligibility criteria. It was also subjected to information bias where the data collection process was limited by variable recording of patient\u0026rsquo;s information by multiple physicians. However, we accounted for this by excluding all cases who had significantly insufficient or missing data.\u003c/p\u003e \u003cp\u003eDespite these limitations, our study is one of the first studies to look at the profile of newly referred glaucoma patients at the largest tertiary eye care center in Saudi Arabia, and adds valuable information to the literature. The collected data helps better understand the demographic differences and patterns of glaucoma in Saudi Arabia, and is expected to work as a future database, providing helpful background information for a series of national community-based epidemiological studies. Once again, this study is not considered a representative sample of the Saudi population but rather a description of a hospital-based population in the largest tertiary referral center in Saudi Arabia. Community-based studies are required for a better allocation and delivery of an efficient eye care system, and perhaps providing hospital-based data from semi-urban places may be of great value in complementing the final picture of a large community-based study. This study also confirms the need for a national screening and intervention program to help early detection and referral of glaucoma cases to prevent late presentation with advanced stages.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;:\u003c/strong\u003eThe study was approved by the Institutional Review Board (IRB) of KKESH (IRB No. RP 2007-R) and adhered to the Declaration of Helsinki and followed the confidentiality requirements of the regional Privacy Act. Patient informed consent was waived by the IRB Committee due to the retrospective nature of the study.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eConsent for publication :\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials :\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests :\u003c/strong\u003e All authors reports no conflicts of interest in this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding :\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions :\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDeema E. Jomar: Literature Review, Resources, Investigation, Writing- Original draft-preparation\u003c/p\u003e\n\u003cp\u003eAbdulrahman Alhomoud: Designing Data Collection form, Data Collection, Resources\u003c/p\u003e\n\u003cp\u003eIbrahim AlObaida: Writing- Reviewing and Editing, Resources\u003c/p\u003e\n\u003cp\u003eNasser AlSobaie: Data Collection, Resources\u003c/p\u003e\n\u003cp\u003eHala Helmi: Data Collection, Resources\u003c/p\u003e\n\u003cp\u003eKhabir Ahmad: Data Analysis , Designing Figures, Writing- Reviewing and Editing\u003c/p\u003e\n\u003cp\u003eOhoud Owaidhah: \u0026nbsp; Writing- Reviewing and Editing\u003c/p\u003e\n\u003cp\u003eKonrad Schargel: \u0026nbsp;Conceptualization, Project administration, Writing- Reviewing and Editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong style=\"text-align: inherit;\"\u003e\u0026nbsp;Acknowledgements :\u0026nbsp;\u003c/strong\u003e\u003cspan style=\"text-align: inherit;\"\u003eThanks to Ms. Samia Timbol \u0026ldquo;Coder/Analyst\u0026rdquo; at King Khaled Eye Specialist Hospital for her great assistance in the acquisition of data needed for this project.\u003c/span\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBourne RRA, Steinmetz JD, Saylan M, et al. 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Published online 2021.\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eAl-Mansouri F, Kanaan A, Gamra H, et al. Prevalence and determinants of glaucoma in citizens of Qatar aged 40 years or older: A community-based survey. \u003cem\u003eMiddle East Afr J Ophthalmol\u003c/em\u003e. 2011;18(2):141\u0026ndash;149. doi:10.4103/0974-9233.80703\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eKhandekar R, Jaffer MA, Al Raisi A, et al. Oman eye study 2005: Prevalence and determinants of glaucoma. \u003cem\u003eEast Mediterr Heal J\u003c/em\u003e. 2008;14(6):1349\u0026ndash;1359.\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eTalaat K, Fathi OT, Alamoudi SM, Alzahrani MG, Mukhtar RM, Khan MA. Types of Glaucoma and Associated Comorbidities Among Patients at King Abdulaziz Medical City, Jeddah. \u003cem\u003eCureus\u003c/em\u003e. 2021;13(6). doi:10.7759/cureus.15574\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eAlzuhairy SA. 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Point prevalence of pseudoexfoliation syndrome in patients scheduled for cataract surgery in eye camps in yemen. \u003cem\u003eMiddle East Afr J Ophthalmol\u003c/em\u003e. 2010;17(1):74\u0026ndash;77. doi:10.4103/0974-9233.61221\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eYildirim N, Yasar E, Gursoy H, Colak E. Prevalence of pseudoexfoliation syndrome and its association with ocular and systemic diseases in Eskisehir, Turkey. \u003cem\u003eInt J Ophthalmol\u003c/em\u003e. 2017;10(1):128\u0026ndash;134. doi:10.18240/ijo.2017.01.21\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eYalaz M, Othman I, Nas K, et al. The frequency of pseudoexfoliation syndrome in the Eastern Mediterranean area of Turkey. \u003cem\u003eActa Ophthalmol\u003c/em\u003e. 1992;70(2):209\u0026ndash;213. doi:10.1111/j.1755-3768.1992.tb04125.x\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eEkstr\u0026ouml;m C, Winblad von Walter L. Incidence and baseline risk factors for pseudoexfoliation in Sweden: a long-term follow-up study. \u003cem\u003eActa Ophthalmol\u003c/em\u003e. 2020;98(3):310\u0026ndash;314. doi:10.1111/aos.14254\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eKarger RA, Jeng SM, Johnson DH, Hodge DO, Good MS. Estimated incidence of pseudoexfoliation syndrome and pseudoexfoliation glaucoma in Olmsted County, Minnesota. \u003cem\u003eJ Glaucoma\u003c/em\u003e. 2003;12(3):193\u0026ndash;197. doi:10.1097/00061198-200306000-00002\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eAl-Bdour MD, Al-Till MI, Idrees GM, Abu Samra KM. Pseudoexfoliation syndrome at Jordan University Hospital. \u003cem\u003eActa Ophthalmol\u003c/em\u003e. 2008;86(7):755\u0026ndash;757. doi:10.1111/j.1755-3768.2008.01258.x\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eAl-Saleh SA, Al-Dabbagh NM, Al-Shamrani SM, et al. 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Changing epidemiology of neovascular glaucoma from 2002 to 2012 at King Khaled Eye Specialist Hospital, Saudi Arabia. \u003cem\u003eIndian J Ophthalmol\u003c/em\u003e. 2017;65(10):969\u0026ndash;973. doi:10.4103/ijo.IJO_33_17\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eAl-Najmi Y, Kirat O, Abdalla Elsayed MEA, Albeedh M, Al-Rashed D, Al-Mohammed A. Glaucoma Diagnoses and Legal Blindness from Glaucoma among Bedouin Patients of Central Saudi Arabia: A Hospital-Based Study. \u003cem\u003eMiddle East Afr J Ophthalmol\u003c/em\u003e. 2021;28(1):29\u0026ndash;35. doi:10.4103/meajo.MEAJO_77_21\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Epidemiology, Glaucoma, Saudi Arabia, Primary angle-closure glaucoma, Primary open-angle glaucoma, pseudoexfoliation glaucoma, neovascular glaucoma","lastPublishedDoi":"10.21203/rs.3.rs-2423328/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2423328/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e: To report the profile of newly referred glaucoma patients to the largest tertiary eye care hospital in Saudi Arabia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and Methods:\u003c/strong\u003e \u0026nbsp;Medical records of all Saudi nationals who presented with glaucoma to the Glaucoma Clinics at King Khaled Eye Specialist Hospital (KKESH) as a first visit through the Eligibility Department, Screening Clinic or Emergency Department between March 2019 and August 2019 were reviewed. Patients underwent a comprehensive glaucoma workup and a detailed documentation of their demographics, clinical exam findings, type and stage of glaucoma at presentation along with previous and offered management. Upon presentation, the stage of glaucoma was compared between eyes with primary glaucoma including primary open-angle glaucoma (POAG), primary angle-closure glaucoma (PACG) and eyes with Secondary glaucoma.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e \u0026nbsp;A total of 532 patients newly presented to KKESH during the study period. The median (interquartile [IQR] range) age of the patients was 63 (17) years, 47.9% of the patients were female. The majority of referred cases came from Riyadh (46.6%), Najran (9.8%) and AlQassim (9.4%) provinces. PACG was the most predominant form of glaucoma (30.5%), followed by POAG. Pseudoexfoliation glaucoma (PSXG) and neovascular glaucoma (NVG) were the most common subtypes among secondary glaucoma. Two out of every five eyes presenting with glaucoma (41.5%) had severe disease.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e In this tertiary setting, PACG was the most commonly encountered glaucoma. A significant proportion of the patients, particularly those with POAG (“the silent thief of sight”) presented with an advanced disease. To limit the irreversible visual loss and socio-economic burden of glaucoma, a large community-based study is required to look into the epidemiology of glaucoma among all Saudi provinces followed by the implementation of a national screening and intervention program.\u003c/p\u003e","manuscriptTitle":"Profile of Newly Referred Glaucoma Patients to the Largest Tertiary Eye Care Hospital in Saudi Arabia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-01-05 18:22:20","doi":"10.21203/rs.3.rs-2423328/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"307b4803-9be9-4dfb-8151-27b2a2e9eb52","owner":[],"postedDate":"January 5th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-01-06T04:29:19+00:00","versionOfRecord":[],"versionCreatedAt":"2023-01-05 18:22:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2423328","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2423328","identity":"rs-2423328","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}