Prevalence of visual impairment and its associated factors among adult glaucoma patients attending University of Gondar, Comprehensive Specialized Hospital, Tertiary Eye Care and Training Center, Northwest Ethiopia, 2022

doi:10.21203/rs.3.rs-3562575/v1

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Research Article

Prevalence of visual impairment and its associated factors among adult glaucoma patients attending University of Gondar, Comprehensive Specialized Hospital, Tertiary Eye Care and Training Center, Northwest Ethiopia, 2022

https://doi.org/10.21203/rs.3.rs-3562575/v1

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Introduction:

Glaucoma is a multifactorial optic degenerative neuropathy characterized by the loss of retinal ganglion cells. It poses a significant public health concern as it is the second leading cause of blindness after cataract, and this blindness is irreversible.

Objectives

To assess the prevalence of visual impairment and its associated factor among adult glaucoma patients attending University Gondar, Tertiary Eye Care and Training Center, Northwest Ethiopia, 2022.

Methods and materials:

Institution-based cross-sectional study was conducted on a sample of 423 glaucoma patients selected by systematic random sampling technique from May 15 – June 30, 2022 at University Gondar, Tertiary Eye Care and Training Center. Data was collected through a face to face interview using a pretested structured questionnaire and medical chart review. The descriptive analysis was summarized by frequency, percent and summary statistics. Binary logistic regression was fitted and variables which had P value of < 0.05 in the multivariable model were considered as statistically significantly associated.

Results

The study found 77.6% (95% CI: 74.2%-82.9%) visual impairment among adult glaucomatous participants. Female sex (AOR = 2.45, 95% CI: 1.18–3.48), rural residence (AOR = 2.45 95% CI: 1.91–3.33), primary open angle glaucoma (AOR = 1.83, 95%CI: 1.35–2.97), advanced stage of glaucoma (AOR = 2.54, 95%CI: 1.05–6.17), and longer duration of diagnosis (AOR = 3.89, 95%CI: 2.29–6.58) had statistically significant association with visual impairment among adult patients with glaucoma.

Conclusion and recommendation:

Visual impairment is found to be significantly higher among adult glaucoma patients attending University of Gondar, Comprehensive Specialized Hospital, Tertiary Eye Care and Training Center. Female sex, rural residence, primary open angle glaucoma, advanced stage of glaucoma, and longer duration of diagnosis had statistically significant association with visual impairment among adult glaucoma patients. Early detection and management of glaucoma is vital to reduce glaucoma related visual disability meaningfully.

Visual impairment

Glaucoma

Adult

Ethiopia

Gondar

Glaucoma is a set of irreversible, progressive optic neuropathies that can lead to severe visual field loss and blindness. It is an important cause of blindness worldwide. A continuous effort to improve early detection and appropriate treatment is the main strategy used to reduce the number of patients suffering from visual loss caused by the late diagnosis of glaucoma.

The two most common forms of glaucoma, primary open-angle glaucoma and primary angle-closure glaucoma affect more than 2 million Americans and are increasing in prevalence(1). Most patients with glaucoma were asymptomatic in the early stages of disease; leading to delayed diagnosis and inappropriate treatments for preventing blindness. Disability of visual function can affect lifestyle and compromise overall quality of life (2, 3).

Risk factors include elevated intraocular pressure, advanced age, African ancestry and elevated intraocular pressure is a well-known major risk factor for glaucoma. In addition, there is growing evidence that vascular factors may play a role in glaucoma pathogenesis(4). Systemic (e.g. hypertension, diabetes) and ocular vascular factors (e.g. ocular blood flow, ocular perfusion pressure) have been assessed for associations with glaucoma(4).

The World Health Organization (WHO) estimated in a systemic review that glaucoma is the second commonest cause of blindness worldwide(5). Nearly 1.9% of global blindness is caused by glaucoma and this is sadly high in Africa which is around 15% and in Ethiopia, glaucoma is responsible for 5.2% of blindness(6).

Treatment of glaucoma consists of topical or systemic intraocular pressure lowering agents, laser treatment or surgery(7).

Decreased visual functioning due to glaucoma has many disabling consequences in patients’ daily lives that, in turn, alter their quality of life. Glaucoma-related visual disabilities ought to be preventable, although the burden of functional visual impairment due to the disease is not fully recognized(8).

It has been demonstrated that low best corrected visual acuity is related to a decreased ability to perform routine daily activities, increased risk of car accidents and falls, and increased mortality(9). Furthermore, peripheral visual loss is associated with an increased risk of falling, car accidents, and serious injuries.

The prevalence of glaucomatous blindness was 23.8% among patients diagnosed with glaucoma who lived in Thailand(10). Another study done among Egyptian glaucoma patients showed that legal blindness was found in 5% of glaucoma patients. There were high odds for finding eyes with total blindness due to glaucoma. Interventional strategies are recommended regarding visual disability among Egyptian glaucoma patients(11).

Blindness due to glaucoma was associated with an advanced stage of glaucoma at diagnosis, fluctuation of intraocular pressure during treatment, the presence of exfoliation syndrome, and poor patient compliance(12). Additionally glaucomatous blindness prevalence was higher in men than in women and shows typically increases with age(10).

Though the burden of glaucoma was higher in Africa including Ethiopia, there is scarcity of information about the prevalence of visual impairment (VI) and its associated factors among glaucoma patients in Ethiopia. Therefore this study addresses visual impairment among glaucoma patients and its associated factors in Ethiopia.

This institution based cross-sectional study was conducted at the University of Gondar, Comprehensive Specialized Hospital, Tertiary Eye Care and Training Center (UoGCSH-TECTC) from May 15 – June 30, 2022. It is located in Gondar city about 750 kilometers Northwest of Addis Ababa; the capital city of Ethiopia. The center gives services such as medical therapy, surgical therapy, laser therapy, and refraction with optical correction for 31,200 patients per year and serving as a center for training and research (13). Glaucoma patients have been diagnosed and managed for 5 days per week while they can precede their follow up 3 days a week (Monday, Wednesday, and Friday).

Once we exclude participants having hearing and speaking problem, history of psychosocial disorders that would impact their ability to respond to the questionnaire, a total of 415 adult glaucoma patients attending UoGCSH-TECTC were enrolled in the study following a careful sample size determination using single population proportion formula on the assumptions;

Level of significance (α): 5% (with a confidence level of 95%), Marginal error: 5%, P: 0.50. The Z-value of 1.96 was used at 95% CI. (n: sample size, P: proportion, d: marginal error).

n= \(\frac{{{(Z}_{a/2})}^{2}*P(1-P)}{{d}^{2}}\), n=\(\frac{{\left(1.96\right)}^{2}*0.50*0.50}{{0.05}^{2}}\), n = 384

After adding 10% for non-response rate the final sample size was found to be 423.

A systematic random sampling method was used to select the participants. The glaucoma clinic provides service for the attending patients on Monday, Wednesday, and Friday.

From the available information, the average glaucoma patients attending the center were 150 per week which was about 50 in each day and 900 per month and two weeks. The sampling fraction was 2 which is 900/423 and the first patient was selected using lottery method from 1–2 and the other participants were selected by adding the sampling fraction from the first selected person. Among these patients, 24 patients were selected per day and 15 patients were selected in the last day of data collection. If patients attending the clinic were ≤ 24, we took all of them as study participants based on the inclusion criteria.

Operational definition

Visual impairment:

Distance VI

Presenting distance visual acuity worse than 6/12 (14).

Blind

Presenting distance visual acuity worse than 3/60(14).

Category	Presenting distance visual acuity worse than;	Equal to or better than
No VI		6/12
Mild VI	6/12	6/18
Moderate VI	6/18	6/60
Severe VI	6/60	3/60
4 blindness	3/60	1/60
5 blindness	1/60	Light perception
6 blindness	No light perception

Near VI

Presenting near visual acuity worse than N6 or N8 at 40cm with existing correction (14).

Psychosocial disorder

Individuals with a mental health condition interacts with a social environment that presents barriers to their equality with others(15).

Data collection tool and procedures

Data were collected by using Amharic version of a pretested, structured questionnaire consisting of questions for the prevalence of VI and its associated factors. Face to face interview to estimate VI and patient’s medical chart review using check list to determine clinical factors was employed by 4 trained BSc optometrists and supervision were done by two MSc optometrist and principal investigator.

Data quality was indemnified by passing three critical steps. Translating questionnaire in to the local language Amharic and retranslating back by language experts was the first one. Then pretest was done on 5% (22) of the sample size at the Felege Hiwot Referral Hospital and necessary modifications were made accordingly. Finally, training data collectors for a day with daily supervision throughout data collection was mandatory. Before analysis, the principal investigator reviewed the collected data for completeness, accuracy, and clarity, as well as clean up and cross-checking.

Data processing and analysis

The data were entered into epi info version 7 and exported to, checked, cleaned, and analyzed by using Statistical Package for Social Sciences (SPSS) version 26. The analysis was done by the investigator using the same statistical package. Descriptive statistics such as proportion, frequency, ratios, and summary statistics were calculated.

Binary logistic regression was performed to determine factors associated with visual impairment. All variables with p value of less than 0.2 were entered to multivariable logistic regression for analysis. Those variables with p-value less than 0.05 in the multivariable logistic regression analysis were considered statistically significant. Adjusted Odds Ratio (AOR) with 95% confidence interval (CI) was used to show the strength of association.

Socio-demographic and economic characteristics of study participants

A total of 415 participants completed the study with a response rate of 98.1%. The mean age of the participants was 56.53 years with standard deviation of 12.08. From the total participants 305 (73.5%) were females, 313 (75.4%) were married, 120 (28.9%) were unable to read and write, 157(37.8%) were farmer and 234 (56.4%) were urban residents. The median monthly family income of the respondents was 2000 Ethiopian birr (ETB) with (IQR = 3000 Ethiopian birr) (Table 1).

Table 1

Socio-demographic characteristics of adult glaucoma patients attending UoGCSH-TECTC, Northwest Ethiopia, 2022 (n = 415)
Variables	Category	Percent	Frequency
Age in years
	18–40	10.1%	42
	41–60	55.7%	231
	≥ 61	34.2%	142
Sex
	Male	26.5%	110
	Female	73.5%	305
Residence
	Urban	56.4%	234
	Rural	43.6%	181
Religion
	Christian	84.3%	350
	Muslim	15.7%	65
Marital status
	Single	5.8%	24
	Married	75.4%	313
	Divorced	8.7%	36
	Widowed	10.1%	42
Educational status
	Can’t read and write	28.9%	120
	Read and write only	36.1%	150
	Primary education	8.9%	37
	Secondary education	12.8%	53
	Collage and above	13.3%	55
Occupation
	Farmer	37.8%	157
	Self employed	12.6%	52
	Civil servant	10.6%	44
	Merchant	15.4%	64
	Retired	23.6%	98
Average family monthly income (in Ethiopian Birr)
	≤ 1000	27.5%	114
	1001–1900	19.5%	81
	1901–4000	30.4%	126
	> 400	22.6%	94
Family history of glaucoma
	Yes	19.5%	81
	No	80.5%	334
n: Sample size

Clinical characteristics of the study participants

Regarding the ocular clinical characteristics, the most prevalent type of glaucoma was primary open angle glaucoma 236 (56.9%). Most of the participants had moderate glaucoma 166 (40%), duration of diagnosis greater than twelve month 269(64.8%), bilateral glaucoma 290(69.9%) and the majority of patients were only on drug treatment 348(83.9%) (Table 2).

Table 2

Clinical characteristics of adult glaucoma patients attending at UoGCSH-TECTC, Northwest Ethiopia, 2022 (n = 415)
Variables	Category	Percent	Frequency
IOP in mmHg
	< 21	55.7%	231
	21–30	33.3%	138
	> 30	11.0%	46
Cup to disc ratio
	≤ 0.65	16.1%	67
	0.7–0.9	62.9%	261
	> 0.9	21.0%	87
Type of glaucoma
	Primary open angle glaucoma	56.9%	236
	Pseudoexfoliative glaucoma	16.6%	69
	Angle closure glaucoma	18.8%	78
	Secondary open angle glaucoma	7.7%	32
Severity of glaucoma
	Mild	16.6%	69
	Moderate	40.0%	166
	Advanced	29.7%	123
	Absolute	13.7%	57
Laterality of glaucoma
	Bilateral	76.1%	316
	Unilateral	23.9%	99
Type of treatment
	Drug only	83.9%	348
	Drug and surgery	16.1%	67
Duration of diagnosis
	≤ 12 month	30.1%	125
	> 12 month	69.9%	290
History of eye surgery
	Yes	32.0%	133
	No	68.0%	282
Chronic systemic illness
	Yes	30.1%	113
	No	69.9%	302
n: Sample size

Prevalence of visual impairment

In the present study the prevalence of glaucomatous visual impairment was 77.6%.

One hundred and forty five glaucoma patients (34.9%) had moderate visual impairment and 135 (32.5%) glaucoma patients had blindness (Fig. 1).

Figure 1

Prevalence of visual impairment among adult glaucoma patients attending at UoGCSH-TECTC, Northwest Ethiopia, 2022

Factors associated with visual impairment

From variables separately entered in to bi variable logistic regression model sex, residence, religion, occupation, IOP, cup to disc ratio, type of glaucoma, severity of glaucoma, laterality of glaucoma, type of glaucoma treatment, duration of diagnosis, history of eye surgery, chronic medical illness had a p value of less than 0.2 then fitted to multivariable logistic regression. Finally significant association was determined by enter method in the multivariable logistic regression and significance was considered with P value of < 0.05 at 95% CI and the following variables were found to have a significant association with VI among glaucoma patients.

The likelihood of VI was about two folds higher among women as compared to men (AOR = 2.45, 95% CI: 1.18–3.48). Being rural resident were nearly two and half times more likely to become visually impaired as compared with participants resided in urban area. (AOR = 2.45 95% CI: 1.91–3.33).

Study participants with duration of diagnosis greater than twelve months were nearly four times more likely to be visually impaired compared with participants with duration of diagnosis < 12 months (AOR = 3.89, 95%CI: 2.29–6.58).

This study shows that patients contracted with primary open angle glaucoma (POAG) were nearly two times more likely to get VI compared with those who had secondary open angle glaucoma (SOAG) (AOR = 1.83, 95%CI: 1.35–2.97). Similarly study participants with absolute glaucoma were 2.54 (AOR = 2.54, 95%CI: 1.05–6.17) times more likely to be visually impaired compared with those who had mild glaucoma (Table 3).

Table 3

Factors associated with visual impairment among adult glaucoma patients attending at UoGCSH-TECTC, Northwest Ethiopia, 2022 (n = 415)
Variable	Visual impairment		COR(95%CI) AOR(95%CI)
Variable	Yes (# and %) No (# and %)		COR(95%CI) AOR(95%CI)
Sex
Female	168 (55.1%)	137 (44.9%)	2.23(1.37–3.36)	2.45(1.18–3.48)*
Male	40 (36.4%)	70 (63.6%)	1.00	1.00
Residence
Rural	76(42.0%)	105(58.0%)	2.79(1.21–3.65)	2.45(1.91–3.33) *
Urban	132 (56.4%)	102 (43.6%)	1.00	1.00
Religion
Christian	184 (52.6%)	166 (47.4%)	1.00	1.00
Muslim	24 (36.9%)	41 (63.1%)	0.53(0.31–0.91)	0.62(0.32–1.19)
Occupation
Farmer	91 (58.0%)	66 (42.0%)	1
Self employed	25 (48.1%)	27 (51.9%)	0.67(0.36–1.26)	0.79(0.37–1.67)
Civil servant	20 (45.4%)	24 (54.6%)	0.60(0.31–1.18)	0.65(0.30–1.43)
Merchant	30 (46.9%)	34 (53.1%)	0.64(0.36–1.15)	0.61(0.30–1.23)
Retired	42 (42.8%)	56 (57.2%)	0.54(0.33–0.91)	0.59(0.32–1.08)
IOP in mmHg
< 21	125 (54.1%)	106 (45.9%)	1.00	1.00
21–30	57 (41.3%)	81 (58.7%)	0.60(0.39–1.91)	0.69(0.41–1.15)
> 30	26 (56.5%)	20 (43.5%)	1.10(0.58–2.09)	1.12(0.52–2.40)
Cup to disc ratio
≤ 0.65	32 (47.8%)	35 (52.2%)	1.00	1.00
0.7–0.9	132 (50.6%)	129 (49.4%)	1.12(0.65–1.91)	1.30(0.67–2.52)
> 0.9	44 (50.6%)	43 (49.4%)	1.12(0.59–2.12)	1.10(0.52–2.34)
Type of glaucoma
Primary open angle glaucoma	110 (46.6%)	126 (53.4%)	1.99(1.47–2.07)	1.83(1.35–2.97) *
Pseudoexfoliative glaucoma	40 (57.9%)	29 (42.1%)	1.56(0.67–3.63)	1.57(0.59–4.17)
Angle closure glaucoma	43 (55.1%)	35 (44.9%)	1.39(0.61–3.18)	0.75(0.28–2.02)
Secondary open angle glaucoma	15 (46.9%)	17 (53.1%)	1.00	1.00
Severity of glaucoma
Mild	31 (44.9%)	38 (55.1%)	1.00	1.00
Moderate	83 (50.0%)	83 (50.0%)	1.23(0.70–2.15)	1.32(0.67–2.62)
Advanced	65 (52.8%)	58 (47.2%)	1.37(0.76–2.48)	1.88(0.91–3.91)
Absolute	29 (50.9%)	28 (49.1%)	1.27(0.63–2.56)	2.54(1.05–6.17)*
Laterality of glaucoma
Unilateral	37 (37.4%)	62 (62.6%)	1.00	1.00
Bilateral	171 (54.1%)	145 (45.9%)	0.98(0.24–3.14)	0.32(0.33–4.06)
Type of treatment
Drugs only	162 (46.5%)	186 (53.5%)	1.00	1.00
Drug and surgery	46 (68.6%)	21 (31.4%)	2.52(1.44–4.39)	1.89(1.00-3.58)
Duration of diagnosis
≤ 12 month	34 (27.2%)	91 (72.8%)	1.00	1.00
> 12 month	174 (60.0%)	116 (40.0%)	4.02(2.54–6.35)	3.89(2.29–6.58)*
History of eye surgery
Yes	75 (56.4%)	58 (43.6%)	1.45(0.96–2.19)	1.51(0.92–2.50)
No	133 (47.2%)	149 (52.8%)	1.00	1.00
Chronic medical illness
Yes	70 (61.9%)	43 (38.1%)	0.93(0.24–3.01)	0.76(0.04–2.99)
No	138 (45.7%)	164 (54.3%)	1.00	1.00

#: Number, ^*: P value < 0.05, IOP: Intra Ocular Pressure, mmHg: millimeter of mercury.

After performing this analytic analysis for glaucoma patients attending in UoG-ECTC, it was confirmed that the prevalence of visual impairment to be 77.6% (95% CI: 74.2%-82.9%). Of this amount of visual impairment the moderate one is the largest compartment with 34.9% frequency followed by total blindness (32.5%).

The prevalence of visual impairment from this study is higher than studies conducted in Netherlands (26%) (16), Ireland (45%)(17), Finland (16%) (12), and India (26%)(18). This discrepancy might be occurred due to socioeconomic difference, operational definition of VI, methodological difference, difference in study population and sample. Study from India uses visual field as additional criteria to measure VI that can underestimate proportion of visual impairment. Additionally study from Netherlands assesses the prevalence of end-of-life visual impairment in patients followed for glaucoma than assessing at point in time which was done for this study.

The level of visual impairment among glaucoma patients is higher among female study participants as compared to males. This could be due to sociocultural domination of males in this community. In most of Ethiopian community males are bread winners of the family and this condition creates abnormal privilege for males to get early checkup of their health.

Residence is among variables that have significant association among glaucomatous study subjects; being from rural area was up to two and half times more prone for visual impairment than those resided in urban. This could be due to behavioral status of rural residents like considering traditional eye medicine as a choice for their eye problem that might delay their follow up, adherence to medications and follow up. This condition could facilitate the occurrence of VI among glaucomatous rural resident.

The odds of being visually impaired is up to two fold higher among participants suffering from POAG as compared to SOAG. The reason behind might be patients who have POAG usually presents lately to the clinic or hospital until vision has become worse because of asymptomatic nature of the disease initially than those patients who have SOAG.

Absolute stage glaucoma is more than two times likely to get visual impairment as compared to mild glaucoma. This study finding is consistent with studies done in USA(19, 20). This condition has occurred due to the fact that the raised amount of retinal nerve fiber layer loss as the stage of glaucoma increased. This progressive nature of glaucoma and permanence of visual impairment makes early detection and intervention vital to protect the community from highly compromised quality of life or make the day to day activity simple.

The odds of developing VI is around four times higher among glaucoma patients having duration of diagnosis one year and above as compared to glaucomatous patients diagnosed within 1 year. As the disease chronicity increase, therapy related, follow up related and socioeconomic related uncertainties can be encountered to facilitate the damage on optic nerve fiber layer. This could be the possible reason that associates duration of diagnosis with VI occurrence.

Significantly higher magnitude of visual impairment has been found among of adult glaucoma patients. Female sex, rural residence, primary open angle glaucoma, advanced stage of glaucoma, and longer duration of diagnosis had statistically significant association with visual impairment among adult patients with glaucoma.

AOR--------------------Adjusted Odd Ratio

CI-----------------------Confidence Interval

COR-------------------Crude Odd Ratio

IOP--------------------Intra Ocular Pressure

POAG--------------------Primary Open Angle Glaucoma

SOAG-------------------- Secondary Open Angle Glaucoma

SPSS---------------------Statistical Package for Social Science

VI------------------------- Visual Impairment

UoGCSH-TECT-------- University of Gondar, Comprehensive Specialized Hospital, Tertiary Eye Care and Training Center

Acknowledgments

Before all, I gratefully acknowledge the University of Gondar, College of Medicine and health Science for the financial support provided and the material support to conduct the study.

Furthermore, I would like to thank my study participants and data collectors for their patience and cooperation throughout the data collection period.

Again, my sincere appreciation also goes to my colleagues for their priceless guidance and Support for the data handling and analysis process.

Ethics approval and consent to participate

Ethical clearance was obtained from University of Gondar, College of Medicine and Health Sciences, Comprehensive specialized hospital and School of Medicine ethical review committee and official letter was obtained. Oral informed consent was obtained from study participants based on declaration of Helsinki. They were allowed to participate, refuse, withdrawal from the study at any time they want. Confidentiality of the information obtained was assured by coding and locking of the data. Participants got enough information about glaucoma and the study.

Consent for publication

Not applicable

Availability of data and materials

The datasets during and/or analyzed during the current study available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

There is no funding provided for this research.

Authors' contributions

G.S done text conception, design of the work, the acquisition and analysis.

B.L wrote the main manuscript and review and edits the discussion and

G.T reviewed the manuscript, tittle selection and supervises the whole research procedure of this study.

F.A supervision throughout data collection, and design of the work.

All authors reviewed the manuscript.

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No competing interests reported.

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Prevalence of visual impairment and its associated factors among adult glaucoma patients attending University of Gondar, Comprehensive Specialized Hospital, Tertiary Eye Care and Training Center, Northwest Ethiopia, 2022

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Abstract

Introduction:

Objectives

Methods and materials:

Results

Conclusion and recommendation:

Figures

Introduction

Methods and materials

Operational definition

Visual impairment:

Data collection tool and procedures

Data processing and analysis

Results

Socio-demographic and economic characteristics of study participants

Clinical characteristics of the study participants

Prevalence of visual impairment

Factors associated with visual impairment

Discussion

Conclusion

Abbreviations

Declarations

Acknowledgments

Ethics approval and consent to participate

Not applicable

Availability of data and materials

Competing interests

References

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