Living Conditions Associated with Advanced Glaucoma

People walking on a side road in a rural village in Tamil Nadu State of Southern India
Researchers say the absence of work and rural residency were both factors in a South Indian population.

People who are not currently working and those who live in rural areas have greater odds of presenting with advanced glaucoma, researchers found in a study of southern Indian populations that was published in Ophthalmology Glaucoma.

Researchers investigated the reasons for patients’ presentation at early and late stages of glaucoma, which is a leading cause of irreversible blindness that patients often do not recognize because it can be mistaken for other reversible causes of vision loss like refractive error or cataract, they said.

The 161 patients (98 men and 63 women, average age of 60.8 years) who participated in the study presented with newly diagnosed primary glaucoma at the glaucoma clinic of Aravind Eye Hospital from December 2018 to May 2019. Patients who did not have a definite diagnosis of glaucoma, were already on glaucoma medications, were primary angle closure suspects (PACS), and those who had had primary angle closure (PAC), secondary glaucoma, or ocular hypertension were excluded from the study.

The researchers classified the patients (64 with advanced glaucoma (cup-to-disc ratio of at least .85 in either eye) and 97 without advanced glaucoma) as having primary open angle glaucoma (POAG), which included patients with normal tension glaucoma, and primary angle closure glaucoma (PACG). The vast majority (148 or 91.9% patients) were referred for concern of glaucoma by another doctor/service (61% from the general ophthalmology clinics at the hospital) and 13 (8.1%) presented directly for glaucoma screening. Of the 13, 8 had family history of glaucoma, 1 had blindness in the family, 1 came for a second opinion for surgery and 3 were glaucoma suspects 3 years ago but were lost to follow up. Researchers reported no significant association between the place where the patients first detected glaucoma and the stage of the glaucoma (P =.18). A total of 26 patients had completed an undergraduate college degree, 67 were employed and 53 women were homemakers. About half (46%) of the patients lived in urban areas while 54% lived in rural areas. 

The primary reason for presentation was defective vision, as 89 patients described. Routine general ophthalmic evaluation (21 patients reported) and referral as glaucoma suspect (37 patients) were other common reasons. Less common reasons included symptoms of ocular surface pathology, ocular trauma, pain around the eyes, glares and halos, headache, and floaters.

In univariate logistic regression analysis, older age (P =.01, odds ratio (OR): 1.47, 95% confidence interval (CI): 1.08–1.98) and people who are not currently employed (P <.001, OR: 3.97, 95% CI: 2.03–7.76) were found to be at greater odds of presenting with advanced glaucoma, whereas college graduate or more education (P =.02, OR: 0.47, 95% CI: 0.24–0.90) and living in urban area (P =.01, OR: 0.45, 95% CI: 0.24–0.86) were found to be associated with a decreased odds of advanced glaucoma.

In multivariable analysis, which included all factors with P <.1 in univariate analyses, participants not employed currently were more likely to present with advanced glaucoma than employed participants (P <.001, OR: 4.19, 95% CI: 1.95–8.99), as were people who lived in rural areas compared with those who lived in urban areas (P =.04, OR: 0.46, 95% CI: 0.21–0.99). Age and education did not show significant association in multivariable analysis.

Presenting with complaints of defective vision was associated with late presentation of glaucoma (P =.03, OR: 2.00, 95% CI: 1.06-3.79).

The researchers recommended providing screening camps or developing local primary eye care centers in rural areas, more thoroughly educating the public about the importance of awareness of family history and detection of glaucoma before visual symptoms are present, and training patients to encourage their family members to get screened.

Limitations of the study include that the severity of glaucoma was based on the amount of cupping instead of the functional visual field defects.


Odayappan A, Kavitha S, Ramulu ST, Upadhyaya S, Venkatesh R. Assessment of reasons for presentation in new primary glaucoma patients and identification of risk factors for late presentation. Ophthalmology Glaucoma. Published online December 3, 2020. doi:10.1016/j.ogla.2020.11.007