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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 59  |  Issue : 2  |  Page : 148-151

Prevalence and etiology of glaucoma emergencies during coronavirus disease-2019 lockdown at a tertiary eye center in India


Department of Glaucoma, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India

Date of Submission01-Dec-2020
Date of Acceptance21-Feb-2021
Date of Web Publication24-Jun-2021

Correspondence Address:
Dr. Premanand Chandran
Aravind Eye Hospital, Avinashi Road, Coimbatore - 641 014, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_177_20

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  Abstract 


Aim: This study aims to report the prevalence and etiology of emergencies in glaucoma during coronavirus disease-2019 lockdown at a tertiary eye care center in India. Materials and Methods: Retrospective case study. Patients who presented with acute onset of pain, redness, blurred vision, and intraocular pressure (IOP) >21 mm Hg between March 25 and May 3, 2020 were included in the study and those who came for scheduled follow-up visit were excluded from the study. Results: Two hundred and ninety-four patients were seen in glaucoma services during the study, of which 43 patients (eyes) met the inclusion criteria. Mean age of the study population was 56.4 ± 16.7 years. Mean visual acuity at presentation was 4/60 and mean IOP was 37.9 ± 10.5 mm Hg. Most common etiology for seeking emergency glaucoma care was secondary glaucoma post vitreoretinal surgery (27.9%), followed by lens-induced glaucoma (25.5%), neovascular glaucoma (11.6%), primary angle closure disease (9.3%) of which 4.6% had acute primary angle closure, inflammatory glaucoma (9.3%), closed globe injury (6.9%), and others (9.3%). 37% of eyes underwent surgery, 5% eyes underwent laser and 58% eyes were treated medically. Conclusions: The prevalence of emergency in glaucoma was 14.6% during the lockdown. Secondary glaucoma constitutes 88.4% and primary glaucoma constitutes only 11.6% of emergency in glaucoma.

Keywords: Glaucoma emergency, ocular emergency, secondary glaucoma


How to cite this article:
Chandran P, Sahu A, Vimalanathan M, Thilagar SP, Arunaachalam V, Dhavalikar M, Raman GV. Prevalence and etiology of glaucoma emergencies during coronavirus disease-2019 lockdown at a tertiary eye center in India. TNOA J Ophthalmic Sci Res 2021;59:148-51

How to cite this URL:
Chandran P, Sahu A, Vimalanathan M, Thilagar SP, Arunaachalam V, Dhavalikar M, Raman GV. Prevalence and etiology of glaucoma emergencies during coronavirus disease-2019 lockdown at a tertiary eye center in India. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2021 Jul 27];59:148-51. Available from: https://www.tnoajosr.com/text.asp?2021/59/2/148/319277




  Introduction Top


Glaucoma is the leading cause of irreversible blindness in the world. Glaucoma generally is an asymptomatic disease with a prevalence of 1.6%–4% in South Indian population.[1],[2],[3] It is often diagnosed on a routine eye examination but in a small proportion of patients, it can present with acute symptoms such as pain, redness, headache, blurred vision, and vomiting due to sudden rise in intraocular pressure (IOP). The prevalence of emergency in glaucoma among ocular emergencies was reported between 0.8% and 1.2%.[4],[5] Acute rise in IOP can occur in angle closure glaucoma, lens-induced glaucoma, trauma, neovascular glaucoma (NVG), inflammatory glaucoma, drug-induced and after intraocular surgery.[6],[7],[8],[9],[10],[11],[12]

During novel coronavirus disease-2019 (COVID-19) pandemic, as a measure to contain the infection spread government of India had issued complete lockdown of the country. During this time, only emergency services were running in our hospital. To the best of our knowledge, there were no studies in the literature which looked in detail the etiology for seeking emergency glaucoma care. Hence, we would like to report the prevalence and etiology of emergencies in glaucoma during the COVID-19 lockdown period in a tertiary eye care center in South India.


  Materials And Methods Top


We retrospectively reviewed the records of all patients who presented to the emergency services between March 25 and May 3 at Aravind Eye Hospital, Coimbatore. The study was approved by the institute ethics committee and adheres to the tenants of Declaration of Helsinki. Patients who presented with acute onset of pain, redness, blurred vision, and IOP >21 mm Hg were included in the study and those who came for scheduled follow-up visit were excluded from the study.

The data collected were age, gender, best-corrected visual acuity (BCVA), IOP, corneal changes, pupil size and response to light, lens status, gonioscopic findings, optic disc findings, number of antiglaucoma medications (AGM), diagnosis, previous ocular surgery, B-scan ultrasonography in patients whose posterior segment was not visible and the line of management. In patients who underwent surgery intraoperative details such as type of surgery, intraocular lens, and complications were noted. At the last follow-up visit, data collected were BCVA, IOP, optic disc findings, and AGM usage. IOP was measured with iCare tonometer during the study.

Statistical analysis mainly consisted of descriptive analysis. Mean and standard deviation was used to assess continuous variables. Statistical analysis was performed using commercial software (Stata ver. 13.1; StataCorp, College Station, TX, USA).


  Results Top


During the study period of 40 days, 1636 patients reported to the hospital for a checkup. Of the 1636 patients, 294 (18%) patients were seen in glaucoma clinic, of which 43 (14.6%) patients (eyes) were categorized as emergency. Twenty-five patients presented with pain, and 18 patients presented with pain, redness and blurred vision. Mean age of the study population was 56.4 ± 16.7 (range, 6–85) years. Mean visual acuity was 4/60 (range, 6/6 to perception of light) and mean IOP was 37.9 ± 10.5 (range, 22–60) mm Hg. All eyes were on AGM at the time of presentation with a mean 2.3 ± 0.8 (range, 1–4).

Twenty-two eyes had corneal edema at the time of presentation. Fourteen eyes were pseudophakic, and the rest were phakic with mature cataract in 11 eyes, immature cataract in 5 eyes, subluxated lens in 1 eye, and clear lens in 12 eyes. Optic disc findings were available for only 22 eyes with mean cup to disc ratio of 0.6 (range, 0.3–0.8) and in the rest 21 eyes disc could not be assessed due to hazy media. Gonioscopy details were available for 31 eyes, of which 22 eyes had open angles, 8 eyes had occludable angles, and 1 eye had angle recession. The most common etiology for seeking emergency glaucoma care was secondary glaucoma post vitreoretinal surgery (12 eyes, 27.9%), followed by lens-induced glaucoma (11 eyes, 25.5%), NVG (5 eyes, 11.6%), primary angle closure disease (4 eyes, 9.3%) of which 2 eyes had acute primary angle closure (APAC), inflammatory glaucoma (4 eyes, 9.3%), closed globe injury (3 eyes, 6.9%), and others (4 eyes, 9.3%). Mean follow-up period was 17 ± 21.5 days (range, 0–68) and 17 patients visited the hospital only once. [Table 1] shows the demographics of the study population.
Table 1: Demographics of the study population

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All the 11 eyes with lens induced glaucoma underwent cataract surgery with intraocular lens implantation. Mean visual acuity improved from perception of light to 6/24 and mean IOP reduced from 36.7 ± 9.5 mm Hg with 2.3 ± 0.8 AGM to 12.8 ± 3 mm Hg with 0.2 ± 0.6 AGM at the last follow-up visit. Three eyes underwent partial silicone oil removal, 2 eyes with APAC underwent laser peripheral iridotomy (LPI), 1 eye underwent trabeculectomy, 1 eye underwent partial release of sulfur hexafluoride (SF6), and rest of the eyes were treated medically.


  Discussion Top


COVID-19 poses a great threat to humanity which results in lockdown of majority of the world to prevent the spread of the virus. As a result all health-care providers were resorted to treat only patients with emergency symptoms and regular appointment patients were rescheduled for a later date. In India, complete lockdown was implemented in 2 phases starting from March 25 and continued till May 3. Later complete lockdown was relaxed slowly with conditions.

During the study, we have seen 1636 patients (mean 40.9 per day) which were comparable to 42.57 per day reported by Das and Narayanan[13] 294 patients (mean 7.4 per day) were seen in the glaucoma clinic which was more than 75 patients (mean 2.7 per day) reported by Das and Narayanan.[13] Of these 294 patients, 43 (14.6%) patients (eyes) were categorized as emergency, of which 38 (88.4%) eyes were glaucoma secondary to other ocular conditions and 5 (11.6%) eyes were primary glaucoma. Remaining 251 patients were either postoperative patient or on AGM who came for follow-up.

Increased IOP post vitreoretinal surgery (27.9%) was the most common cause for seeking emergency glaucoma care in our study. The prevalence of glaucoma post vitreoretinal surgery was reported to range between 15% and 20% for uncomplicated pars plana vitrectomy (PPV) and it increases to 56% in case of additional SF6 or silicone oil tamponade.[12] Out of the 12 eyes which had increased IOP post vitreoretinal surgery in our study, 4 eyes underwent surgery (3 eyes partial silicone oil removal and 1 eye partial SF6 removal) for the IOP control and the rest were controlled with AGM.

Lens-induced glaucoma constitutes about 25.5% of glaucoma emergency in our study. The prevalence of lens-induced glaucoma was reported to be 1.5% among senile cataract. Phacomorphic glaucoma was reported to be more common than phacolytic glaucoma.[14] In our study, we found phacolytic glaucoma (6 eyes) to be more common than phacomorphic glaucoma (5 eyes). All eyes underwent lens extraction with posterior chamber intraocular lens implantation except one which underwent iris-fixated intraocular lens (IFIOL) implantation due to lack of capsular support. The visual acuity improved in all eyes except one which had the IFIOL. Ten eyes had normal optic nerve head in the postoperative period and in one eye disc was not documented due to hazy media at the last follow-up visit. Only one eye was on AGM in the postoperative period rest all eyes had normal IOP without AGM at the last follow-up visit.

Primary glaucoma constitutes about 11.6% of glaucoma emergency. Of the 5 eyes, 2 were diagnosed with primary angle closure glaucoma (PACG), 2 were APAC and 1 was ocular hypertension. Both the eyes with PACG were post LPI. Of the 2 eyes with PACG, IOP was controlled with AGM in one eye, and the other eye underwent trabeculectomy for uncontrolled IOP. In the eye that underwent surgery, the vision was maintained at 6/36 both pre and post trabeculectomy, and IOP was 9 mm Hg without AGM at the last follow-up visit. APAC constitutes about 0.1% of ocular emergency.[15] The incidence of APAC has been reported between 3.8 and 12.2 per 100,000 people per year.[16],[17],[18],[19],[20] Both the eyes with APAC in our study underwent LPI as well as their fellow eyes which were diagnosed with primary angle closure suspect. One eye with ocular hypertension was treated medically.

NVG was reported to constitute 5.8% of glaucoma patients in a tertiary hospital.[9] In our study, 5 (11.6%) eyes seeking emergency glaucoma care were diagnosed with NVG. The etiology for NVG was central retinal vein occlusion in 3 eyes and proliferative diabetic retinopathy in 2 eyes. All eyes were treated medically. The prevalence of secondary glaucoma was reported to be 10% in patients with uveitis.[10] Four (9.3%) eyes in our study seeking emergency care were diagnosed with inflammatory glaucoma and all eyes were treated medically. The prevalence of traumatic glaucoma was reported to be 6.6% among ocular trauma.[8] In our study, 3 (6.9%) eyes had secondary glaucoma post trauma, of which one eye underwent lens extraction with PPV for subluxated lens in to the vitreous cavity. In the remaining 2 eyes, IOP was controlled with medical management.

Limitations of our study were its retrospective nature, short follow-up and lost to follow up as some of the patients were reviewed with the referring ophthalmologist postsurgery due to lockdown. The prevalence of emergency in glaucoma may be higher in our study because of less number of patients turned up for regular follow-up visits due to lockdown.


  Conclusions Top


The prevalence of emergency in glaucoma was 14.6% during the study. Patients with secondary glaucoma seek emergency glaucoma care more often than patients with primary glaucoma.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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