Original Article Philippine Journal of OPHTHALMOLOGY

Clinical Profile and Demographics
of Glaucoma Patients Managed in a
Philippine Tertiary Hospital
Jose Ma. Martinez, MD1,2 and Mark Angelo B. Hosaka, MD
Eye Institute, St. Luke’s Medical Center
1

E. Rodriguez Sr. Blvd., Quezon City

Eye Institute, St. Luke’s Medical Center
2

Bonifacio Global City, Taguig, Metro Manila

Correspondence: Jose Ma. Martinez, MD
Eye Institute, St. Luke’s Medical Center
E. Rodriguez Sr. Blvd., Quezon City
Email: eyesmart@gmail.com

Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article.

ABSTRACT

Objective: To determine the demographic and clinical profile of glaucoma patients seen in a Philippine tertiary
hospital from 2011 to 2014.

Method: Medical records of glaucoma patients managed at the outpatient ophthalmology clinic from October
2010 to August 2014 were reviewed. Diagnosis of glaucoma was based on the International Society of Geographic
and Epidemiological Ophthalmology (ISGEO) guidelines. The demographics, clinical profile, functional severity
scoring, and initial management of patients were described.

Result: Majority of the 570 patients were females (60.17%), with a mean age of 56.23 years. Eighty-five percent
claimed to have no family history of glaucoma. The mean best-corrected visual acuity (BCVA) was 0.40, the mean
intraocular pressure (IOP) was 23.56 mmHg, and the mean cup-to-disc (CD) ratio was 0.69. There were more
primary type of glaucoma (55.48%) than secondary glaucoma. Mixed pattern was the most common type of visual
field pattern at initial presentation. Majority of the defects were under GSS 2 stage 2 of mean deviation (MD) and
loss variance (LV). Medical treatment was the most common initial management given to glaucoma patients.

Conclusion: The primary glaucomas were more common than the secondary glaucomas seen in a private tertiary
hospital. Most had moderate visual field damage (mixed type pattern) and the most common initial management
given was medical treatment.

Keyword: Glaucoma, Epidemiology, Primary open angle glaucoma, Primary angle closure glaucoma, Secondary
glaucoma, Normal tension glaucoma, ISGEO guidelines

Philipp J Ophthalmol 2015;40:81-87

July - December 2015 81

Uveitic guidelines and determined the distribution of severity 3. In 2010.8%7. The study was carried out in accordance of angle-closure glaucoma2-5. with evidence of glaucoma. The Brusini Glaucoma Staging System was 2.2. it has been estimated that 60 million Study Design people have open angle and angle closure glaucoma. and the initial management of the 1. was a hospital-based cross-sectional study11 published 2. It was also utilized in the study to estimate peripheral anterior synechiae. respectively. and race. or excessive pigment Our study focused on further characterizing deposition on the trabecular surface. or medical The International Society of Geographic and records were available confirming glaucomatous visual Epidemiological Ophthalmology (ISGEO) guidelines12 morbidity. or difference in valence studies on glaucoma locally although there vertical cup-to-disc ratio between 2 eyes of >0. Luke’s Medical Center ophthalmology out- Compared to Caucasians or the black race. such as patients13.6. Diagnosis where the optic disc cannot be assessed and the types of glaucoma seen in a public tertiary hospital.1 The charts of glaucoma patients managed at the St. It ocular pathology with evidence of glaucoma as defined above. determined the prevalence. the severity of glaucoma. Diagnosis based on the presence of structural and functional evidence where there is intraocular pressure Currently. glaucoma was The diagnosis of glaucoma in cross-sectional prevalence surveys ranked as the third most common cause of bilateral blindness. and the fifth most common cause of low The presence of glaucoma would be based on three levels of vision. iris whirling (distortion of the radially orientated iris fibers). affecting all age groups. Thailand. gender. elevated intraocular pressure. this number will increase by 20 million. age and sex distribution. It determined the clinical profile and demographics Secondary Glaucoma is defined as having a secondary form of of glaucoma patients seen from 2011 to 2014. Primary Angle Closure Glaucoma (PACG): PAC together using standard internationally accepted terminology. studies in Singapore. 3.10 evidence: 1. Neovascularization different types of glaucoma based on the ISGEO 2. Primary Angle Closure Suspects: An eye in which an studies. it has patient clinic from October 2010 to August 2014 were been observed that Asians have a higher prevalence reviewed. International Society for Geographic and Epi­ primary angle closure glaucoma was the most common demiological Ophthalmology (ISGEO) Classification of Glaucoma. or VA <20/200 (LogMAR 0. Secondary glaucoma will be categorized as such: clinical features. there are no population-based pre­ >20mmHg. 82 Philippine Academy of Ophthalmology .7%9 (Table 1). In a Philippine population- based survey done in 2001 to 2002. Trauma of visual field loss using the Brusini’s Glaucoma 4. Singapore and Thailand showed a higher prevalence of primary open angle glaucoma while Table 1.10) and intraocular pressure >21 mmHg types of glaucoma seen in other settings.9%8. type seen in Myanmar. visual field testing is impossible but with VA <20/200 There is still further need to gather more data on the (LogMAR 0. glaucoma cases seen in a Philippine tertiary hospital 3. Myanmar. The optic disc does not have glaucomatous damage. Glaucoma is the leading cause of irreversible METHODOLOGY blindness worldwide. hospital. “glaukomflecken” lens opacities. Population-based with the tenets of the Declaration of Helsinki. Primary Angle Closure (PAC): An eye with an occludable drainage angle and features indicating that trabecular developed to classify visual defects seen in glaucoma obstruction by the peripheral iris has occurred. By 2020. Lens Related 5. The guidelines were applied to glaucoma appositional contact between the peripheral iris and cases seen in the charity division of a private tertiary posterior trabecular meshwork is considered possible. vertical cup-to-disc ratio >0. were developed to standardize identification of the Classification of Primary Angle Closure (PAC) different types of glaucoma across epidemiological 1. as defined above.2%6.10) in an eye which shows evidence of glaucoma filtering surgery. Surgical Staging System 2. Diagnosis based solely on structural evidence where visual previously showing the prevalence and distribution of field testing was not satisfactorily completed. 3. and 2. 4. and India Diagnosis of the presence of glaucomatous optic showed a prevalence of glaucoma among patients 40 neuropathy was based on the ISGEO guidelines12 years old and above at 3.

At presentation. and TOP strategy). Majority of the 570 patients. or digital wide perimetry.23 years. Philippine Journal of OPHTHALMOLOGY Clinical Examination anti-glaucoma medication after glaucoma filtering surgery or insertion of glaucoma drainage device.69. A worse visual acuity and/or visual-field defects were p value less than 0. or transscleral stimulus.. mixed. were females (60. age.December 2015 83 . laser surgery.91% had eye presentation. size III white laser trabeculoplasty (SLT/ALT). standard deviation. the Snellen chart and converted to LogMAR values. At calculated summarizing the continuous and categorical least two perimetry studies with reproducible visual variables. Ohio. reliable if there was <20% fixation losses and <33% false-positive and false-negative errors. USA). significant anterior segment disease. Germany). included in the analyses. and glaucoma drainage device. A total of 711 patient charts were reviewed. Modes of intervention were classified as: observation. Koeniz Switzerland) or a 4-mirror Zeiss lens Initial management was defined as the therapy (Carl Zeiss. instituted within the first two weeks of diagnosis. Koeniz. Perimetry of Statistics and Data Analysis patients diagnosed with previous retinal laser treat- ment. error of refraction. best-corrected visual acuity (BCVA) 56. Chi-square and Fisher’s tests determined defects were included in the study. Switzerland) (LI). Standard automated perimetry (SAP) was used to quantify glaucomatous functional damage with the Laser procedures included laser iridotomy Octopus perimeter (Haag-Streit. tabulated.56 mmHg. USA). severity of glaucoma based on 0. initial management. mean age of of glaucoma. initial intraocular pressure (IOP) at 74% (344) had blurring of vision and 15. percentages) and frequency distri­bution were glaucomatous optic neuropathy were excluded. field lens (Volk Optical Inc. Intraocular whether the loss was localized. July .17%). Data Collection RESULTS The following data were obtained. range. Refraction was based on the current corrective lens power or automated refractor. it applicable to both Humphrey and Octopus lamp with the use of a Volk 78D. 90D. or generalized. One and organized using Microsoft Excel 2011: name hundred forty-one cases had no glaucoma and were and file number of patient. Gonioscopy was performed with a 3-mirror Goldman lens (Haag- Streit. vertical cup-disc ratio (CDR) and CDR pain or photophobia (Table 2). diagnosis. The eye with the statistical significance among compared variables. trabe­ culectomy. the mean IOP was 23. peripheral iridoplasty (PIR). making vertical cup-disc ratio (CDR) was estimated at the slit. NY.13 The GSS 2 tonometer (Haag-Streit. pressures were obtained twice and averaged. The mean BCVA was asymmetry. etiology of secondary glaucoma.05 was considered significant. Switzerland) or the determined the severity of visual field loss and Tonopen (Reichert AMETEK. Visual Field Testing anti-glaucoma medication. The The system used MD and PSD or LV values. Intraocular pressure Severity of glaucoma was based on Brusini’s was obtained with either the Goldman applanation Glaucoma Staging System (GSS) 2. use of CDR was 0. Koeniz. The test was considered cyclophotocoagulation (TSCPC). and non. sex. macular pathology. and refraction. Best-corrected visual acuity was obtained using surgical intervention after failed initial management. and the mean GSS 2 at presentation. selective or argon using tG2 program (central 30 degrees. family history excluded.40. extreme Descriptive statistics (mean.

than secondary glaucomas (31%) (Table 3).45 0.61) 0 Absolute 42 (22.77) Range 4 – 64 Not elicited 5 (4.40 ± 0.21) Lens 17 9.02) Hyperopia 54 (46.68) Range 20 – 84 10 – 89 23 – 84 Hand movement (HM) 28 (29.17) Secondary Glaucoma 176 30. 0.76 6.55) 34 (30.35) 8 (7.38 No 36 (27. Table 2.29) Mean 23.52 26.8 pain.0 Yes 94 (72.65 1.28 No light perception (NLP) was more commonly seen initially in POAG.0 Primary Angle Closure Glaucoma (PACG) 138 24. age M:F com- VA CD cent Mean nosis ber ± SD ratio plaints1 ± SD ratio NLP IOP primary open angle glaucoma (POAG) (22.48%) glaucoma.68 28. Most primary glaucomas were diagnosed with BOV.83) Congenital 11 1.24 1:1.91 Without 397 (84.79) 25 (65. 0.24 ± 15.49 0.97) Trauma 23 13.45) Unknown 19 (16. Demographic and visual characteristics of the Table 3.66) 34 (30.55 + 10.43) Asymptomatic 4 (0.63) 10 (29.9 Variables PACG POAG NTG Age (years) Other visual acuity (%) Mean ± SD 60.18) 4 (11. Eye redness/tearing 27 (5.54) 29 (85. BOV. There was a higher female PACG 138 60.07 Not elicited 15 (3.08 Male 227 (39.90 Mean ± SD 56.5 – 89.94) Bilateral Cup-disc ratio (CDR) Presentation Mean ± SD 0.45) Family history IOP (mmHg) on presentation Without 96 (83.09) *Others included other secondary causes of glaucoma not classified into Eye pain/photophobia 74 (15.53 bilateral disease at presentation with no family history ± 15.07 Ocular Hypertension 22 3.24 (Table 4).23 ± 18.12) 12 (35.66 1:2.66 20.2:1 pain.91) 67 (52.3 – 8. pseudoexfoliation.69) 42 (36.11) Male 36 (26.63) 12 (35.55) Light perception (LP) 14 (14. Best-corrected visual acuity and NTG.79) Pattern of visual field defect (%) Refraction Emmetropia 17 (14.47) Gender (%) Counting finger (CF) 21 (22.88 No light perception (NLP) 32 (33. Loss of vision (LOV)/blindness 16 (3.81 Presentation (%) Others* 17 9.66 Uveitic 12 6.38) 14 (12. Comparison of PACG. Type n % Variables n (%) Primary Open Angle Glaucoma (POAG) 127 22.17) 31 (28.46 redness ± 0.73 63.50 63.80 Age (years) Normal Tension Glaucoma 44 7.24) 13 (29. study population (N=570).26 Range 0 – 0.48) 71 (64. but none had bilateral NLP 1 Top 3 chief complaints were considered 2 BOV .74 8. Mean ± SD 0.21) Range 0.09) 60 (47. Demographic characteristics of PACG.30 glaucoma ± 19.58) Table 5. PAOG.69 ± 0.blurring of vision (Table 5).73 preponderance in PACG and normal tension glaucoma LOV3 ± 0.85) any subcategory of secondary glaucoma based on ISGEO guidelines. POAG 127 63. POAG.97 Female 343 (60.78 Primary Angle Closure (PAC) 5 0. and anterior segment dysgenesis.24 (NTG). 3 LOV .86) Table 4.30) Generalized 65 (34.80%) BOV2. 0.65 Blurring of vision (BOV) 346 (74. were similar in occurence. steroid-induced.74) Female 102 (73.78) This included elevated episcleral venous pressure.loss of vision 84 Philippine Academy of Ophthalmology .50 LOV ± 0.40 0.21) 13 (34.30) Localized 12 (6.27) 1 (2.95 Range 0.40) Mixed 67 (36.66 ± 12.78%) and Diag- Num.64 5.74 With 14 (12.41) 29 (26.16 ± 11.1 pain.31) 74 (63. Types of glaucoma in the study population. and secondary There were more primary glaucomas (55.83) Neovascular 42 23.86 With 56 (11.90 Gender (%) Primary Angle Closure Suspect (PACS) 45 8.95) Myopia 26 (22.99 Family History (%) Surgical 72 40.76) 31 (70. Primary Mean Chief Mean Vertical Per- angle closure glaucoma (PACG) (24. Secondary 176 48.33 ± 12.

09) 11 (20. POAG. 23 (26.55) 12 (27. Philippine Journal of OPHTHALMOLOGY Table 6.80) 31. 49 (27. **LV .December 2015 85 .27) 0 0.74.56- 2.81%) and PACG (33. 3 (21.75) 35. 10 (15.91) 5.38). 95% CI).41.45) 2 13 (29.18) 39.47) 76. There were 10 cases secondary percent of PACG required at least one surgery during to elevated episcleral venous pressure (Sturge-Weber the course of their follow up (Table 10). 0 0 1 (2.99- 20. 2 (50.89.03) 51.67.0) 0 3 (6. laser treatment as glaucomas (Tables 5. Age-specific prevalence of PACG.0.56% glaucoma.47 and LV: p=0.14.09) 23 (41. 0 1 (5.67.84) Medical treatment was the most common initial Patients with secondary glaucoma were younger.24- 4. The LI1/PIR2 50 42.80) Absolute 16 (36.54- 8. 41.80 The most common type of visual field pattern Laser 118 23.81.44. 0 4 (57. 12 (37. syndrome and carotid cavernous fistula).27.31- 22. 57 (31. 25 (27. 26 (28.67.09) 69.85) 47.63) 67. No patient presented with 4 SLT .71- 20.67.27) 0 25.32) 84. 6 (75. Age PACG POAG Secondary Variables PACG POAG NTG group Glaucoma Pattern of defects (%) (years) Male Female Male Female Male Female Mixed 27 (49. 5 steroid- Table 8.27) 2 (4. 27 (14.82%. 11 (34.86- 25.84- 0. MD* (%) 69.18) 11 (25. Sixty as the main causes.46.argon laser trabeculoplasty July . 1 (25. secondary glaucoma (%. Pattern of defects and severity among PACG. 5 ALT .23) 25. 4 2 (4.0. POAG.55) 51 – 60 15 (23. *MD . with penetrating keratoplasty treatment was more commonly done in secondary and pars plana vitrectomy with or without silicone oil glaucoma (36.92.38- 11.94) Localized 4 (7.selective laser trabeculoplasty absolute glaucoma in both eyes.0.65 at initial presentation was the mixed pattern seen Observation 58 11.89. induced.32) 83. 11 (57.55) 1 – 10 0 0 1 (14.94) 20.86) 82.93- 6.58) 54.37 in 49. Initial treatment given at first consultation. 4 0 0 0 35.27) 1 (1.5.33.78- 43.81) 23.0.55) 1 (2. Majority of the Cataract extraction + trabeculectomy 17 3. 38 (44.81- 1.85) 85.72) 83.82) 8 (14.94) 47.0. 2 23 (52. 4 (16.12- 19.97) 36.09) 3 (6.0.75- 31. Among those with secondary the initial management was performed in 55.59 glaucomatous defects were under GSS 2 stage 2 of Laser treatment mean deviation (MD) and loss variance (LV). 6 (60. and 14.57- 25.82) 51.45) 37.36) 8 (14.19.94) 92.18) 3 8 (18.0) 0 31 – 40 1 (5.09.07.73) 8 (18.38.mean deviation 10.82) 0 14.09) 20 (45.loss variance 26.64- 27. 6 (66.64) 20 (36.27) 21 (47. 5 (26.14. this TSCPC3 23 19.04- 35.44.55% of PACG.49.27- 7.14 Trabeculectomy 90 17.80) 38. and Table 7. Twenty-two percent 1 LI .0) 0 >61 years 15 (17. 13 (14. 6). Type of Initial Treatment n % Medical Therapy 203 39.peripheral iris retraction of patients presented with absolute glaucoma.55) 2.45) 9 (20. Among PACG. 1 pseudoexfoliation. management given to glaucoma patients in general with higher mean IOP compared to the primary (Tables 8 and 9).57.82) 2 (4.36) 11 (25.27- 36. 1 (12. and NTG. 1 15 (34.17- 21. 24 (38. 12 (66.5. Absolute 0 0 0 24.69 difference.41) 48.85- 8.32.49 SLT4/ALT5 2 1.64) 38.56.43.67.17- 34. Glaucoma drainage device (GDD) 21 4.53- 10.84) 54.69) 1 26 (59.00) 1 (1. 0 16 (66.45) 7 (15.97) 26.0.26. Severity of defects 4.18) 87.82) 0 11 – 20 0 1 (25.71) 33.33 Goniotomy 3 0. more 3 TSCPC .55) 1 (2.09%.99- 10.42. 2.laser iridotomy 2 PIR .76) 60.78. was not statistically significant (MD: p=0.12 and NTG respectively (Table 7).58.15) 50.12- 18.37 proportion of patients with higher MD and LV LI 43 36.59) Severity of defects LV** (%) 41 – 50 2 (8. Generalized 24 (43. Absolute 16 (29.87. POAG.09) 9 (20. and 1 anterior segment dysgenesis (ICE syndrome).68- 46. 3 (30.33%).56- 40.27) 21 – 30 3 (16. 3 4 (9.86.44 was greater among POAG than PACG patients.93- 15. however.29.transcleral cyclophotocoagulation frequently seen in PACG. 1 (7. 6 (42.93- 21. surgically-induced type accounted for (Table 9) while surgical intervention as the initial almost 41% (Table 3).

71) 29 (26.88) 32 (23.81) ISGEO guidelines. This could be attributed drugs (%) to the presence of other ocular pathology that 0 71 (63. That study showed that physicians took the intraocular pressures and assessed 86 Philippine Academy of Ophthalmology .20) fistula.82) 65 (47.72) Not applicable 3 (2.22) 1 12 (10.72) recommended.28) 61 (58.90) of the subcategories of secondary glaucoma is 3 0 0 0 1 (0. Table 9.09) from Sturge-Weber syndrome and carotid-cavernous Surgeries (%) 0 39 (34. the comparable with the study done by FlorCruz II.98) demiologic study that used Brusini’s glaucoma staging Yes 38 (34.81) 18 (52.19) institution could also lead to more secondary glaucoma 4 3 (2. The following could account for the LI 21 (35. and 1 67 (59.88) 7 (5.85) 5 (14.15) glaucoma in this study.57) 53 (36.56) 0 9 (6.08) There was also a high proportion of secondary Surgery 36 (33.82) 55 (50. the most common was PACG. Primary open angle glaucoma subtypes of glaucoma.73) 6 (5. The presence of 2 12 (10.82) 43 (39. There were 5 cases of in quantifying functional severity of glaucomatous juvenile open angle glaucoma (JOAG) grouped under damage in patients.85) 0 3 (2.43) 75 (52.71) 43 (39.10) pseudoexfoliation glaucoma.34) 1 (3. might cause a falsely of a private tertiary hospital.59) 34 (100.33) system to determine the functional damage and Not applicable 40 (36.71) a well-established subspecialty referral system in the 3 11 (9.94) 59 (46. Patients with DISCUSSION previous retinal laser procedure or with significant anterior segment pathology were excluded in the study. This study differed from a similar to determine its clinical application. Glaucoma Medical therapy 12 (11. in contrast to the Laser treatment 60 (55.80) referrals.65) 31 (93. POAG. Distribution of PACG. study done by FlorCruz II as a result of differences Since this was a retrospective study.69) 0 16 (11. the most common cause GDD 2 (5. and of surgical procedures performed.44) 17 (100) 1 (100. cataract. The secondary glaucomas were also diagnosed Secondary at a younger age.0) 0 0 3 (18.07) Surgery after laser (%) To the author’s knowledge.0) 34 (64.11 prevalence of open angle glaucoma would be higher Despite its limitations.25) differences: the increasing prevalence of diabetic SLT/ALT 0 2 (25.56) 0 0 19 (35. Among the primary high staging score.33) 17 (16. the GSS 2 is an objective method than the angle closure types.59) 2 (5.23) 2 (1. different in disease classification.56) 8 (7.68) 2 (1.75) TSCPC 5 (8.85) 0 8 (5.04) 100 (92.20) 32 (30.33) 5 (62.70) identifying the different components of visual field loss in glaucoma patients. Distribution of PACG.11) 79 (75. and PACG was the most common type of glaucoma secondary glaucoma according to initial treatment given at seen in a government tertiary hospital. different classification of glaucoma from the ISGEO Variables PACG POAG NTG Secondary guidelines. and higher intraocular pressures compared Glaucoma to the primary glaucomas. with worse visual acuities upon Variables PACG POAG NTG Glaucoma diagnosis. however. this is the first epi­ No 33 (29.68) 2 (1. 5 0 0 0 1 (0.85) 2 (1.96) 27 (96. POAG.48) 2 (5.45) Glaucoma drugs There were also several causes of glaucoma in after surgery (%) this study not classified under any category based on No 46 (42.39) 13 (12.0) 117 (90.89) 7 (6.29) 61 (44.85) surgical followed by neovascular. thus. Not applicable 1 (0. There were 10 cases of glaucoma Yes 18 (16.06) 42 (32.81) Trabeculectomy 34 (94. the presence of dense cataract was not glaucoma being managed at the social service division evaluated in the study and.5) 0 13 (81.51) 11 (10. and improved secondary glaucoma according to need of glaucoma drugs surgical techniques for dealing with complicated or surgery. NTG.5) 0 0 prevalent.81) 3 (8. This study provided information on the types of However. Further studies are recommended the POAG group.78) 0 4 (2. had the highest rate of absolute glaucoma.11 It used a first consultation.82) 19 (17. NTG.79) 3 (2.04) 9 (26.09) secondary to increased episcleral venous pressure Not applicable 45 (41.0) 0 0 retinopathy.77) 2 (6.58) 0 27 (21. Further expansion 2 2 (1.67) 1 (12.91) contributed to worse visual function.47) 21 (15.11) previous study where lens-related and trauma were LI/PIR 34 (56. Most patients were seen at relatively earlier stages of the disease.93) 29 (85. the increasing frequency and complexity Table 10.94) 33 (23. this was If POAG and NTG were combined.71) 41 (29. five cases of steroid-induced glaucoma.

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