Glaucoma

The Prevalence and Types of Glaucoma in an Urban Indian

Population: The Singapore Indian Eye Study
Arun Narayanaswamy,1 Mani Baskaran,1 Yingfeng Zheng,1,2 Raghavan Lavanya,1 Renyi Wu,1
Wan-Ling Wong,1,4 Seang-Mei Saw,1,3,4 Ching-Yu Cheng,1,3,4 Tien-Yin Wong,1,3,4 and Tin Aung1,4
1
Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
2
State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
3Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
4
Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health
System, Singapore

Correspondence: Tin Aung, Singa-
pore National Eye Centre, 11 Third
Hospital Avenue, Singapore 168751;
aung.tin@snec.com.sg.
Submitted: March 1, 2013
Accepted: May 30, 2013
Citation: Narayanaswamy A, Baskaran
M, Zheng Y, et al. The prevalence and
types of glaucoma in an urban Indian
population: The Singapore Indian Eye
Study. Invest Ophthalmol Vis Sci.
2013;54:4621–4627, DOI:10.1167/
iovs.13-11950
PURPOSE. To determine the prevalence and types of glaucoma in an urban Singaporean Indian
population.
METHODS. The Singapore Indian Eye Study (SINDI) was a population-based, cross-sectional
survey that examined 3400 (75.6% response) persons aged 40 to 80 years. Participants
underwent a standardized examination including slit-lamp biomicroscopy, Goldmann
applanation tonometry, and dilated optic disc assessment. Participants suspected to have
glaucoma also underwent visual field examination (24-2 SITA standard, Humphrey Visual
Field Analyzer II), gonioscopy, and repeat applanation tonometry. Glaucoma was defined
according to International Society for Geographical and Epidemiologic Ophthalmology
criteria.
RESULTS. Of the 3400 participants, 78 (2.29%) had diagnosed glaucoma, giving an age-
standardized prevalence of 1.95% (95% confidence interval [CI], 1.5%–2.5%). The age-
standardized prevalence of primary open-angle glaucoma (POAG) was 1.25% (95% CI,
0.89%–1.73%), primary angle-closure glaucoma (PACG) 0.12% (95% CI, 0.04%–0.33%),
and secondary glaucoma 0.55% (95% CI, 0.35%–0.86%). The mean IOP among the
participants in the normal group in the study population was 15.6 6 2.6 mm Hg and
17.7 6 6.1 mm Hg in subjects with glaucoma (P ¼ 0.003). The mean central corneal
thickness (CCT) in the normal study population was 540.31 6 33.79; the mean CCT in
subjects with POAG (529.8 6 30.8 lm) was statistically different from the normal study
group (P ¼ 0.003).
CONCLUSIONS. The prevalence of glaucoma among Singaporean Indians 40 years of age and
older in Singapore was 1.95%, approximately half that of the Chinese and the Malay persons
in Singapore. As in other Asian studies, POAG was the main form of glaucoma accounting for
nearly 60% of cases.
Keywords: glaucoma, epidemiology, population, intraocular pressure

T he impact of migrant communities on disease prevalence is

gaining importance in the current era of globalization.1–4
Sustained migration between disparate health environments
also affects the longer-term epidemiology of chronic noninfec-
tious diseases, and it has been suggested that this could have an
impact on health services at migrant destinations.5 This impact
needs to be recognized, and establishing data on migrant
population disease statistics would help unravel some of the
environmental and socioeconomic effects on disease preva-
lence, and it may aid the development of effective strategic and
operational approaches to health care delivery.6–8
The urbanized society of Singapore has an amalgam of
immigrants predominantly from China, Malaysia, and India. The
Singaporean Indians are the third largest population subset in
the island, accounting for 9.2% of the population and also
comprise nearly 10.0% of the total population in neighboring
Malaysia.9 This migrant Indian community set foot into the
region during the late 18th century and early 19th century and
in the initial few decades, this migration predominantly
occurred from the southern states of India.10 Currently
available population-based data from the Indian subcontinent
with regard to glaucoma prevalence has shown significant
variations based on geographic location and has also been
reported to be largely influenced by urbanization.11–14 Since
the record of immigration of Indians has been documented to
be close to 130 years,10,15 we found this subset of Singaporean
Indian population to be an ideal sample to evaluate the impact
of migration on disease prevalence. The Singapore Indian Eye
Study (SINDI)16 was designed to document the prevalence, risk
factors, and impact of the major eye diseases in ethnic Indian
residents of Singapore, most of whom were migrants from
South India.
In this study, we describe the prevalence, type, and visual
impact of glaucoma among Indian persons aged 40 to 80 years
residing in Singapore.

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 Glaucoma Prevalence Among Singaporean Indians
METHODS
Study Design
SINDI was a population-based, cross-sectional study of 3400
Indian adults aged ‡40 years conducted between the years
2007 and 2009. Details of the study design, sampling plan, and
methodology have been reported.16 In brief, the study was
conducted in the southwestern part of Singapore, using the
same study protocol as the Singapore Malay Eye Study.17 On
the basis of an age-stratified random sampling strategy, 6350
names were selected. Of these, 4497 individuals were deemed
eligible to participate. The term ‘‘Singaporean Indians’’ refers
to persons of Indian descent who migrated to Singapore. The
study adhered to the Declaration of Helsinki, ethics approval
was obtained from the Singapore Eye Research Institute
Institutional Review Board, and written informed consent
was obtained from all participants.
Clinical Assessment
All subjects recruited in the study were examined at a research
clinic established at the Singapore Eye Research Institute. An
interviewer-administered questionnaire was used to collect
demographic data, socioeconomic information, lifestyle fac-
tors, and medical, ophthalmic, and family history. The
presenting visual acuity with habitual correction and best
corrected visual acuity with subjective refraction were
recorded using an Early Treatment Diabetic Retinopathy Study
(EDTRS) logarithm of the minimal angle of resolution (log
MAR) number chart (Lighthouse International, New York, NY)
at a distance of 4 m.17 Central corneal thickness (CCT) was
measured using ultrasound pachymetry (Nidek Echoscan
Model US-1800, Nidek Co., Ltd., Gamagori, Japan). Ocular
assessment was performed by a team of two ophthalmologists
(YZ and RL) with extensive experience in population-based
studies. Slit lamp biomicroscopy (model BQ-900; Haag-Streit,
Koniz, Switzerland) was performed to identify abnormalities of
the anterior segment specifically, evaluating for any evidence of
secondary glaucoma. Peripheral anterior chamber depth (ACD)
was determined by using the modified Van Herick technique,18
with the temporal peripheral anterior chamber examined
under optical section at 316 magnification. Intraocular
pressure (IOP) was measured with a Goldmann applanation
tonometer (Haag-Streit) before pupil dilation. One reading was
taken from each eye. If the IOP reading was greater than 21
mm Hg, a repeat reading was taken, and the second reading
was used for analysis.
Gonioscopy was performed with a Goldmann two-mirror
lens (Ocular Instruments, Inc., Bellevue, WA) under standard
dark illumination in three groups of participants: those
suspected to have glaucoma (definition provided later), all
participants with peripheral ACD of Van Herick grade 2 or less,
and one in five randomly selected participants who did not
meet the first two criteria. A narrow vertical beam of 1 mm in
length was offset vertically for superior and inferior quadrants,
horizontally for nasal and temporal quadrants. Dynamic
indentation gonioscopy with a four-mirror Sussman gonio-
scope (Ocular Instruments, Inc., Bellevue, WA) was used to
determine the presence of peripheral anterior synechiae. Angle
width, iris angle insertion, iris profile, and presence of
peripheral anterior synechiae were documented according to
classification systems by Spaeth19 and Scheie.20
The optic disc was evaluated with a 78-D lens, at 316
magnification, with measuring graticule during dilated fundus-
copy. The vertical cup to disc ratio (VCDR) was calculated and
morphological features such as disc hemorrhage, notching of
the neuroretinal rim (NRR), and defects of the retinal nerve
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IOVS j July 2013 j Vol. 54 j No. 7 j 4622
fiber layer were documented. Finally, automated perimetry
(SITA 24-2; Humphrey Visual Field Analyzer II; Carl Zeiss
Meditec, Inc., Oberkochen, Germany) was performed with
near refractive correction on 1 in 10 participants and in all
participants suspected to have glaucoma (definition in the next
section). The visual field test was repeated if the test reliability
was not satisfactory (fixation loss > 20%; false positive > 33%;
and/or false negative > 33%) or if there was a glaucomatous
visual field defect (definition in the next section). Data from
participants with normal perimetry (429 of 438 normal
subjects; nine subjects had unreliable visual fields) were used
to define normative values for VCDR and IOP for the
population.
Diagnostic Definitions. Suspected glaucoma was defined
as participants’ fulfilling any of the following criteria: (1) IOP >
21 mm Hg, (2) VCDR > 0.6 or VCDR asymmetry > 0.2, (3)
abnormal anterior segment deposit consistent with pseudo-
exfoliation or pigment dispersion syndrome, (4) narrow
anterior chamber angle (defined in the next section), (5)
peripheral anterior synechiae, (6) other findings consistent
with secondary glaucoma, and (7) known history of glaucoma.
As indicated, these participants underwent visual field testing,
gonioscopy, and a second IOP measurement, usually on
another day.
Glaucoma cases were defined according to the International
Society of Geographical and Epidemiologic Ophthalmology
(ISGEO) criteria based on three categories.21 Category 1 cases
were defined as optic disc abnormality (VCDR/VCDR asym-
metry ‡ 97.5 percentile of the normal population or NRR
width between 11 and 1 o’clock or 5 and 7 o’clock reduced to
 0.1 VCDR), with a corresponding glaucomatous visual field
defect. Category 2 cases were defined as having a severely
damaged optic disc (VCDR or VCDR asymmetry ‡ 99.5
percentile) in the absence of adequate performance in a visual
field test. In diagnosing category 1 or 2 glaucoma, it was
required that there be no other explanation for the VCDR
finding (dysplastic disc or marked anisometropia) or visual field
defect (retinal vascular disease, macular degeneration, or
cerebrovascular diseases). Category 3 cases were defined as
subjects without visual field or optic disc data who were blind
(corrected visual acuity < 3/60) and who had previous
glaucoma surgery or had IOP ‡ 99.5 percentile. A glaucoma-
tous visual field defect was considered to be present if the
following were found: (1) glaucoma hemifield test result
outside normal limits, and (2) a cluster of three or more
nonedge, contiguous points, not crossing the horizontal
meridian, with a probability of <5% of the age-matched normal
group on the pattern deviation plot on two separate occasions.
A narrow anterior chamber angle was diagnosed if the
posterior trabecular meshwork was seen for 1808 or less of
the angle circumference during static gonioscopy. Primary
angle-closure glaucoma (PACG) was defined as an eye with
glaucoma as defined in the presence of narrow angles, and
features of trabecular obstruction by peripheral iris (such as
peripheral anterior synechiae, elevated IOP, iris whorling,
‘‘glaukomflecken’’ lens opacities, or excessive pigment depo-
sition on the trabecular surface). Subjects with glaucoma and
an open, normal drainage angle with no identifiable secondary
pathologic processes were said to have primary open-angle
glaucoma (POAG). Other cases in which it was difficult to
accurately assess the underlying cause of the glaucoma, were
termed unclassifiable. Final identification, adjudication, and
classification of glaucoma cases were reviewed by the senior
author (TA) , along with two glaucoma fellowship trained
ophthalmologists (MB and YFZ).
Other Variables. Systolic and diastolic blood pressures
were taken using an automated sphygmomanometer (Dinamap
GE Pro 100V2; GE Health Care, Milwaukee, WI). Nonfasting
 Glaucoma Prevalence Among Singaporean Indians IOVS j July 2013 j Vol. 54 j No. 7 j 4623

TABLE 1. Prevalence of Glaucoma by Age and Sex Among Singaporean Indians

All Persons Males Females

N n (%) N n (%) N n (%)

All glaucoma
40–49 y 957 12 (1.25) 465 9 (1.94) 492 3 (0.61)
50–59 y 1077 17 (1.58) 529 10 (1.89) 548 7 (1.28)
60–69 y 887 29 (3.27) 464 16 (3.45) 423 13 (3.07)
70þ y 479 20 (4.18) 248 9 (3.63) 231 11 (4.76)
P for trend 0.006 0.191 0.005
Crude total 3400 78 (2.29) 1706 44 (2.58) 1694 34 (2.01)
Adjusted total* 1.95 (1.51–2.50) 2.29 (1.59–3.24) 1.66 (1.14–2.41)
POAG
40–49 y 957 11 (1.15) 465 8 (1.72) 492 3 (0.61)
50–59 y 1077 9 (0.84) 529 7 (1.32) 548 2 (0.36)
60–69 y 887 15 (1.69) 464 9 (1.94) 423 6 (1.42)
70þ y 479 11 (2.30) 248 4 (1.61) 231 7 (3.03)
P for trend 0.042 0.870 0.003
Crude total 3400 46 (1.35) 1706 28 (1.64) 1694 18 (1.06)
Adjusted total* 1.25 (0.89–1.73) 1.62 (1.02–2.49) 0.93 (0.54–1.55)
PACG
40–49 y 957 0 (0.00) 465 0 (0.00) 492 0 (0.00)
50–59 y 1077 2 (0.19) 529 1 (0.19) 548 1 (0.18)
60–69 y 887 4 (0.45) 464 3 (0.65) 423 1 (0.24)
70þ y 479 0 (0.00) 248 0 (0.00) 231 0 (0.00)
P for trend 0.329 0.367 0.709
Crude total 3400 6 (0.18) 1706 4 (0.23) 1694 2 (0.12)
Adjusted total* 0.12 (0.04–0.33) 0.14 (0.04–0.55) 0.09 (0.01–0.45)
Values in bold are statistically significant.
* Age-standardized rates (95% CI) based on Singapore Census of Population 2010 (Indian).

blood samples were drawn from all participants to determine
levels of serum glucose and glycosylated hemoglobin (HbA1c).
A subject was labeled hypertensive if the systolic BP ‡ 140 mm
Hg or diastolic BP ‡ 90 mm Hg or physician diagnosis or self-
reported history of hypertension. Diabetes mellitus was
diagnosed in a subject who had a nonfasting glucose level ‡
200 mg/dL (11.1 mmol/L) at examination, or had a physician
diagnosis of diabetes and was using diabetic medications.
Statistical Analysis
Statistical analysis was performed with commercial software
(SPSS; ver. 20, SPSS Inc., Chicago, IL). Prevalence estimate of
glaucoma was performed for the whole cohort and in age- and
sex-stratified groups. Prevalence rates were standardized to the
population distribution from the 2010 Singapore Indian
Census,9 using the direct method of adjustment. Logistic
regression was used to assess the odds of glaucoma with
increasing age. Independent t-test was used for comparison of
means and chi-square or Fisher’s exact test was used for
comparison of proportions between groups. P-value < 0.05
was considered as statistically significant. We also performed a
comparative analysis of the age-specific prevalence of POAG
from prior reports among South Indian subjects aged 40 years
and above.12–14,22
RESULTS
There were 3400 participants in SINDI (75.6% participation
rate). Of the nonparticipants, 1021 (22.7%) refused to
participate and 76 (1.7%) were not contactable. Nonpartici-
pants on average were slightly older than participants (P ¼
0.001), and there were no sex differences (P ¼ 0.28) between
the two groups.
The mean age of the study population was 57.8 6 10.1
years, and 49.8% were women. Mean IOP (right eye) was 15.75
mm Hg, with 97.5 and 99.5 percentiles of 21.0 and 24.0 mm
Hg, respectively. Mean VCDR in the normal study group (right
eye) was 0.41, with 97.5 and 99.5 percentiles of 0.60 and 0.62,
respectively. Mean VCDR asymmetry was 0.03 with 97.5 and
99.5 percentiles of 0.13 and 0.20, respectively. Of the 3400
participants, 365 (10.7%) were classified as having suspected
glaucoma. Of these, 78 (2.29%) had glaucoma, of which 46
(58.97%) had POAG, 6 (7.69%) had PACG, and 26 (33.3%) had
secondary glaucoma. Table 1 shows the overall crude and age-
standardized prevalence of glaucoma, POAG, and PACG. The
age-standardized prevalence rate of glaucoma was 1.95% (95%
confidence interval [CI], 1.51–2.50) with a POAG prevalence
of 1.25% (95% CI, 0.89–1.73) and PACG prevalence of 0.12%
(95% CI, 0.04–0.33). The prevalence of glaucoma increased
with age (P for trend ¼ 0.006) and was higher in participants
aged 60 to 69 years (odds ratio [OR], 2.66; 95% CI, 1.35–5.25; P
¼ 0.005) and 70 to 80þ (3.43; 1.66–7.08; P ¼ 0.001) compared
with those aged 40 to 49 years. The standardized prevalence of
secondary glaucoma was 0.55% (95% CI, 0.35%–0.86%). The
mean IOP among the normal subjects in the study population
was 15.6 6 2.6 mm Hg and 17.7 6 6.1 mm Hg in subjects with
glaucoma (P ¼ 0.003). Of the 46 participants with POAG, 38
(82.6%) of subjects with IOP  21.0 mm Hg and three (50.0%)
of the six participants with PACG had an IOP  21.0 mm Hg.
The mean CCT in the normal study population was 540.31 6
33.79 lm. The mean CCT in subjects with POAG (529.8 6 30.8
lm) was statistically lower than the normal study group (P ¼
0.003).

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 Glaucoma Prevalence Among Singaporean Indians IOVS j July 2013 j Vol. 54 j No. 7 j 4624

TABLE 2. Characteristics and Subtypes of Glaucoma

All Median Age, y Males Females M:F Ratio

Any glaucoma 78 (2.29) 63.23 44 (2.58) 34 (2.01) 22:17

Primary glaucoma 52 (1.53) 61.74 32 (1.88) 20 (1.18) 8:5
Secondary glaucoma 26 (0.76) 66.04 12 (0.74) 14 (0.89) 6:7
Types of glaucoma
POAG 46 (1.35) 61.11 28 (1.64) 18 (1.06) 14:9
PACG 6 (0.18) 63.50 4 (0.23) 2 (0.12) 2:1
PXF glaucoma 2 (0.06) 58.94 0 (0.00) 2 (0.12) 0:1
Neovascular glaucoma 4 (0.12) 56.18 2 (0.12) 2 (0.12) 1:1
Pigment dispersion glaucoma 1 (0.03) 70.64 1 (0.06) 0 (0.00) 1:0
Steroid-induced glaucoma 1 (0.03) 61.92 1 (0.06) 0 (0.00) 1:0
Glaucoma with pseudophakia 13 (0.38) 69.48 7 (0.41) 6 (0.35) 7:6
Unspecified glaucoma 5 (0.15) 65.85 1 (0.06) 4 (0.24) 1:4
Data are number (%) of cases; PXF, pseudo-exfoliation.

Table 2 shows the characteristics of subjects with specific The overall prevalence of glaucoma among Singaporean
types of glaucoma. Among the attributable causes of secondary Indians was 1.95%, with POAG being the most predominant
glaucoma (0.81%), glaucoma with pseudophakia (0.38%) and form at 1.25%. The prevalence of PACG was noted to be rather
neovascular glaucoma (0.12%) were the most common low at 0.12%. There was a significant increase in glaucoma
diagnoses. ISGEO categorization of the glaucomas (Table 3) prevalence with age, and this was higher among females. The
revealed a predominance of categories 1 (53.8%) and 2 (42.3%) glaucoma prevalence in the Singaporean Indian population
in this population. Of the 78 glaucoma cases, 13 (16.6%) had was significantly lower than that of their Chinese (3.4%) and
low-vision (logMAR, >0.30 to <1.00) and eight (10.2%) were Malay (3.2%) counterparts in the Tanjong Pagar Eye Study23
blind (logMAR, ‡1.00), according to the primary definition. and the Singapore Malay Eye Study,24 respectively, which used
The proportion of subjects with low vision was equal (30.7%) the same definitions and classification criteria.
among POAG and PACG subjects. Blindness due to glaucoma The census from year 2000 recorded that Singaporean
was noted to be associated with POAG in two subjects (2.56%) Indians are predominantly persons with ancestry traced to the
and from secondary causes in the remaining six subjects southern region of India (from the states of Tamil Nadu and
(7.69%). Kerala) and account for 66.6% of the Indian community in
The distribution of males compared with females was Singapore.25 A detailed analysis of our study sample revealed
similar in all categories of glaucoma. The associations of age, that the proportion of subjects with a South Indian ancestry
sex, IOP, CCT, myopia, hypertension, and diabetes mellitus was close to 90%. This aspect has important implications
with POAG were evaluated by logistic regression and the data because our data become directly comparable to recent studies
are presented in Table 4. Subjects with POAG were associated on subjects from this region in India, such as the Aravind
with a higher IOP and lower CCT. Out of 78 subjects with
glaucoma, 56 (71.8%) were not aware that they had glaucoma.
Analysis estimating the pooled prevalence of POAG (Figure) TABLE 4. Multiple Logistic Regressions for Risk Factors for POAG
from 17,258 South Indian subjects aged 40 years and above Among Singaporean Indians
from three major studies12,14,22 revealed that an overall
prevalence of POAG of 2.04% (95% CI, 1.30%–2.78%). Further, N OR (95% CI) P
this estimate was 2.53% (95% CI, 0.97%–4.08%) in urban subset
Age group, y
of the population and 1.41 (95% CI, 1.04%–2.78%) among the
rural subset of the population. 40–49 911 Ref
50–59 1000 0.76 (0.31–1.87) 0.543
60–69 803 1.37 (0.58–3.24) 0.480
DISCUSSION 70þ 404 1.83 (0.71–4.72) 0.213
Sex
This study is the first epidemiological study to evaluate the
prevalence of ocular disease in a migrant Indian population. Male 1581 Ref
Female 1538 0.60 (0.32–1.11) 0.104

TABLE 3. Glaucoma Diagnosis Based on ISGEO Categorization IOP, mm Hg 3119 1.11 (1.03–1.20) 0.006
CCT, lm 3119 0.99 (0.98–0.99) 0.019
Category 1 Category 2 Category 3
Myopia
Glaucoma Subtype (%) (%) (%)
Yes 856 1.14 (0.59–2.20) 0.696
POAG 29 (31.17) 17 (21.79) — No 2263 Ref
PACG 3 (3.84) 3 (3.84) — Hypertension
PXF glaucoma 2 (2.56) — —
Yes 1746 0.91 (0.46–1.77) 0.772
Neovascular glaucoma 1 (1.28) 1 (1.28) 2 (2.56)
No 1373 Ref
Pigment dispersion glaucoma 1 (1.28) — —
Steroid-induced glaucoma — 1 (1.28) — Diabetes
Glaucoma with pseudophakia 5 (6.41) 8 (10.25) — Yes 1064 1.13 (0.59–2.18) 0.705
Unspecified glaucoma 2 (2.56) 2 (2.56) 1 (1.28) No 2055 Ref
Total 43 (55.12) 32 (41.02) 3 (3.84)
Ref, reference group.

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 Glaucoma Prevalence Among Singaporean Indians IOVS j July 2013 j Vol. 54 j No. 7 j 4625

FIGURE. Pooled prevalence of POAG in South Indians aged 40 years and older (using crude prevalence figures). APEDS, Andhra Pradesh Eye Disease
Study14; CGS, Chennai Glaucoma Study12; SINDI, Singapore Indian Eye Study; ACES, Aravind Comprehensive Eye Survey.22

Comprehensive Eye Survey (ACES),22 Chennai Glaucoma Study
(CGS),12,13 and the Andhra Pradesh Eye Disease Study
(APEDS).14 A compilation of comparative data from glaucoma
prevalence from various parts of southern India is shown in
Table 5. The POAG prevalence in our study has a close match
to the prevalence noted in ACES with both reporting a
prevalence of 1.2%.22 An important aspect of this data is that
the population sample in ACES was derived from a predom-
inantly rural setting. In comparison, the CGS reported age-
standardized POAG prevalence of 1.57% in the rural arm of
their study and APEDS reported a prevalence of 1.6%.12,14
Although the prevalence of POAG in our sample was lower, the
trend follows that of the rural arms of the CGS and APEDS and
of note, there is an overlap of the confidence intervals (95% CI,
0.89–1.73 vs. 1.19–1.95 [CGS]; 1.13–2.06 [APEDS]).12,14 The
overall prevalence of POAG in our study samples correspond
to the prevalence noted in the rural samples of the ACES, CGS,
and APEDS, which is intriguing. Though the Singaporean
Indians by all means would be considered highly urbanized,
the prevalence of POAG did not match the urban South Indians
of the CGS (3.46%) and the APEDS (4.0%). The authors from
the CGS study attributed the discrepancy of POAG prevalence

TABLE 5. Age-Standardized Rates of POAG and PACG in Comparative Population Subsets from India and Singapore

Study POAG, % (95% CI) PACG, %

Aravind Comprehensive Eye Survey (Rural)24; 1997 1.26 (0.9–1.5) 0.5(0.3–0.7)

Chennai Glaucoma Study (Rural)12,13; 2001* 1.58 (1.19–1.95) 0.87 (0.58–1.16)
Chennai Glaucoma Study (Urban)12,13; 2003* 3.46 (2.9–4.1) 0.88 (0.60–1.16)
Andhra Pradesh Eye Disease Study (Urban)14; 2000* 4.0 (2.74–5.25) 1.8 (0.88–2.70)
Andhra Pradesh Eye Disease Study (Rural)14; 2000* 1.6 (1.13–2.06) 0.7 (0.4–1.1)
Singapore Indian Eye Study (Urban); 2009* 1.25 (0.89–1.73) 0.12 (0.04–0.33)
Singapore Malay Eye Study (Urban)24; 2006* 2.5 (2.4–2.6) 0.12 (0.10–0.14)
Tanjong Pagar Eye Study (Urban)23; 1998* 2.4 (1.6–3.2) 0.8 (0.4–1.3)
Values in bold are from the current study.
* Definition criteria based on ISGEO guidelines.18

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 Glaucoma Prevalence Among Singaporean Indians
between their rural and urban populations to significant
socioeconomic and lifestyle differences.12 Interestingly, these
aspects of urbanization did not seem to affect the prevalence of
POAG among the Singaporean Indians, who may be considered
to have a higher socioeconomic status compared to the rural
and urban counterparts in the CGS or the APEDS. The
prevalence of PACG was also low at 0.12% and matched that
of the Malay subjects in Singapore but was far lower than that
reported in native southern Indian population (0.5%–
1.8%).13,14,22 The urban subjects in the CGS13 and APEDS14
reported rates of 0.80% and 1.8%, respectively, whereas the
prevalence in the rural subjects of ACES,22 CGS,13 and APEDS14
study was 0.5%, 0.85%, and 0.7%, respectively. We have to
acknowledge the likelihood of the disparities between the
urban glaucoma prevalence rates noted between CGS, APEDS,
and our study could be due to differences in methodologies.
The definitions of glaucoma in our study and the CGS were
based on the ISGEO18; however, in the CGS, gonioscopy and
automated perimetry were done for every patient, and this
could have contributed to a higher yield of suspected
glaucoma cases. Further, factors that could contribute to this
large variation could be subjective differences in gonioscopic
assessment and the proportion and mean age of nonrespond-
ers. We noted that there were 1094 (32.1%) nonresponders for
the study; these subjects had a significantly higher mean age
than the responders (61.1 vs. 57.8 years; P < 0.001), and this
could have also partially contributed to the low prevalence
rate. We also considered the possibility of a higher cataract
surgery rate in Singapore as a potential cause for lower
prevalence of PACG but found that the age-adjusted cataract
surgery rates were marginally lower compared to CGS (9.7% vs.
10.16%)26 and far lower than that reported in APEDS (9.7% vs.
14.6%).27
The trend of POAG increasing with age12,14,22,28,29 has been
substantiated in our sample as well, and similarly, the risk of
glaucoma was twice as much in subjects older than 70 years.
Our study noted a higher male preponderance for both POAG
and PACG, but this variation in sex distribution was not
significant and was similar to the findings noted in the urban
subset of APEDS. The CGS also reported equal prevalence of
PACG across the sexes in the urban population (17:17) and a
female preponderance among the rural population (7:27);
however, the authors concluded that this did not translate to
significantly higher prevalence of PACG among the rural
women.13 The mean age of our study population was slightly
higher at 57.8 6 10.1 years compared with 54.8 6 10.6 years
in CGS and 53.2 6 10.9 in APEDS. Despite this, the glaucoma
prevalence in our population was lower, and this could be
partly attributed to differing study methodologies.
Glaucoma with pseudophakia was the predominant catego-
ry of secondary glaucoma at 0.38%, closely matching the
reports from APEDS (0.21%), ACES (0.30%), and SIMES
(0.42%).22,24,30 The CGS reported a fairly high prevalence rate
of glaucoma associated with aphakia and pseudophakia (urban
arm, 0.99%; rural arm, 1.38%).26,31 The authors of CGS
attributed this to inadequate preoperative assessment and
poor quality of surgery especially with these zones of the
country being served by large-scale rural mass camp surgery
programs.31
Glaucoma and eye diseases awareness continues to be a
major public health issue even in the most developed countries
and health care systems.32,33 More than 70% of subjects in this
study were not aware of their glaucoma. Though this is better
than the rate of >80% reported in the urban population of
CGS,34 it did not translate to a lower rate of POAG-related
visual morbidity among the Singaporean Indians (SINDI, 2.56%
versus CGS, 2.2%). In general higher awareness could lead to
improved detection because the health-seeking pattern of an
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IOVS j July 2013 j Vol. 54 j No. 7 j 4626
aware population is likely to be more robust. The current level
of awareness does not seem to translate into this ideal state,
and reasons for this could be due to failure of subjects to report
for routine eye health screenings, high health care costs, or
failure of strategy used in public awareness programs. This
indicates that there is a specific need to look into the strategies
and approaches that could help overcome this deficit.
The SINDI study involved a large number of subjects with a
long history of migration and had a good response rate (75.6%).
The limitations of our study include the lack of visual field and
gonioscopy assessments in all subjects, which could have
contributed to some underestimation of disease, specifically
angle closure. Furthermore, the single reading approach used
for IOP measurements and older age of the nonresponders
could also have led to underestimation of glaucoma prevalence
among the Singaporean Indians.
In summary, the prevalence of glaucoma among Indian
Singaporean persons 40 years of age and older in Singapore
was 1.95%, far lower than the Chinese and the Malay cohorts of
the same population. POAG was the main form of glaucoma,
accounting for 58.9% of disease. Our study involved a large
number of subjects with a long history of migration and had a
good response rate (75.6%). The prevalence of POAG matched
the rural cohorts of the native Southern Indian population and
in contrast, the PACG rate was far lower. The effects of urban
environment on glaucoma prevalence were not obvious among
the Singaporean Indians compared with their South Indian
counterparts.
Acknowledgments
Supported by the Biomedical Research Council (08/1/35/19/550)
and the National Medical Research Council, STaR/0003/2008,
Singapore.
Disclosure: A. Narayanaswamy, None; M. Baskaran, None; Y.
Zheng, None; R. Lavanya, None; R. Wu, None; W.-L. Wong,
None; S.-M. Saw, None; C.-Y. Cheng, None; T.-Y. Wong, None; T.
Aung, None
References
1. Mott IVWH. Globalization: People, Perspectives, and Pro-
gress. Praeger Publishers: Westport, CT; 2004.
2. Appadurai A. Modernity at Large: Cultural Dimensions of
Globalization. University of Minnesota Press: Minneapolis;
1996.
3. Gushulak BD, MacPherson DW. The basic principles of
migration health: population mobility and gaps in disease
prevalence. Emerg Themes Epidemiol. 2006;3:3.
4. Swende TZ, Sokpo J, Tamen FI. Globalization and health: a
critical appraisal. Niger J Med. 2008;17:135–138.
5. Gushulak B, Weekers J, Macpherson D. Migrants and emerging
public health issues in a globalized world: threats, risks and
challenges, an evidence-based framework. Emerg Health
Threats J. 2009;2:e10. doi:10.3134/ehtj.09.010.
6. Salehi R. Intersection of health, immigration, and youth: a
systematic literature review. J Immigr Minor Health. 2010;12:
788–797.
7. Bundred P, Gibbs T. Medical migration and Africa: an
unwanted legacy of educational change. Med Teach. 2007;
29:893–896.
8. Hargreaves S, Friedland JS, Gothard P, et al. Impact on and use
of health services by international migrants: questionnaire
survey of inner city London A&E attenders. BMC Health Serv
Res. 2006;29:153.
9. Singapore Department of Statistics. Singapore in figures 2010.
Ethnic distribution. 2009. Available at: http://www.singstat.
 Glaucoma Prevalence Among Singaporean Indians
gov.sg/publications/publications_and_papers/population_
and_population%20structure/population2012.pdf. Accessed
November 2, 2012.
10. Kernial Singh Sandhu, A Mani. Indian communities in
Southeast Asia. Singapore: Institute of South East Asian
Studies; 2006.
11. George R, Ve RS, Vijaya L. Glaucoma in India: estimated
burden of disease. J Glaucoma. 2010;19:391–397.
12. Vijaya L, George R, Baskaran M, et al. Prevalence of primary
open-angle glaucoma in an urban south Indian population and
comparison with a rural population. The Chennai Glaucoma
Study. Ophthalmology. 2008;115:648–655.
13. Vijaya L, George R, Arvind H, et al. Prevalence of primary
angle-closure disease in an urban south Indian population and
comparison with a rural population. The Chennai Glaucoma
Study. Ophthalmology. 2008;115:655–660.
14. Garudadri C, Senthil S, Khanna RC, Sannapaneni K, Rao HB.
Prevalence and risk factors for primary glaucomas in adult
urban and rural populations in the Andhra Pradesh Eye
Disease Study. Ophthalmology. 2010;117:1352–1359.
15. Report of The High Level Committee on Indian Diaspora.
Available at: http://indiandiaspora.nic.in/diasporapdf/
chapter20.pdf. Accessed November 2, 2012.
16. Lavanya R, Jeganathan VS, Zheng Y, et al. Methodology of the
Singapore Indian Chinese Cohort (SICC) Eye study: quantify-
ing ethnic variations in the epidemiology of eye diseases in
Asians. Ophthalmic Epidemiol. 2009;16:325–336.
17. Foong AW, Saw SM, Loo JL, et al. Rationale and methodology
for a population-based study of eye diseases in Malay people:
the Singapore Malay Eye Study (SiMES). Ophthalmic Epide-
miol. 2007;14:25–35.
18. Foster PJ, Devereux JG, Alsbirk PH, et al. Detection of
gonioscopically occludable angles and primary angle closure
glaucoma by estimation of limbal chamber depth in Asians:
modified grading scheme. Br J Ophthalmol. 2000;84:186–192.
19. Spaeth GL. The normal development of the human anterior
chamber angle: a new system of descriptive grading. Trans
Ophthalmol Soc UK. 1971;91:709–739.
20. Scheie HG. Width and pigmentation of the angle of the
anterior chamber; a system of grading by gonioscopy. Arch
Ophthalmol. 1957;58:510–512.
21. Foster PJ, Buhrmann R, Quigley HA, Johnson GJ. The
definition and classification of glaucoma in prevalence
surveys. Br J Ophthalmol. 2002;86:238–242.
22. Ramakrishnan R, Nirmalan PK, Krishnadas R, et al. Glaucoma
in a rural population of southern India: the Aravind
Downloaded from iovs.arvojournals.org on 03/01/2022
IOVS j July 2013 j Vol. 54 j No. 7 j 4627
comprehensive eye survey. Ophthalmology. 2003;110:1484–
1490.
23. Foster PJ, Oen FT, Machin D, et al. The prevalence of glaucoma
in Chinese residents of Singapore: a cross-sectional population
survey of the Tanjong Pagar district. Arch Ophthalmol. 2000;
118:1105–1111.
24. Shen SY, Wong TY, Foster PJ, et al. The prevalence and types of
glaucoma in Malay people: The Singapore Malay Eye Study.
Invest Ophthalmol Vis Sci. 2008;49:3846–3851.
25. Census of Population 2000. Education, Language, Religion.
Leow, Bee Geok. Available at: http://www.singstat.gov.sg/
publications/publications_and_papers/cop2000/cop2000r1.
html. Accessed November 2, 2012.
26. George R, Arvind H, Baskaran M, Ramesh SV, Raju P, Vijaya L.
The Chennai Glaucoma Study: prevalence and risk factors for
glaucoma in cataract operated eyes in urban Chennai. Indian J
Ophthalmol. 2010;58:243–245.
27. Dandona L, Dandona R. Naduvilath TJ, et al. Population-based
assessment of the outcome of cataract surgery in an urban
population in southern India. Am J Ophthalmol. 1999;127:
650–658.
28. Sommer A, Tielsch JM, Katz J, et al. Relationship between
intraocular pressure and primary open angle glaucoma among
white and black Americans: the Baltimore Eye Survey. Arch
Ophthalmol. 1991;109:1090–1095.
29. Vijaya L, George R, Paul PG, et al. Prevalence of open-angle
glaucoma in a rural south Indian population. Invest Oph-
thalmol Vis Sci. 2005;46:4461–4467.
30. Dandona L, Dandona R, Srinivas M, et al. Open-angle glaucoma
in an urban population in southern India the Andhra Pradesh
Eye Disease Study. Ophthalmology. 2000;107:1702–1709.
31. Arvind H, George R, Raju P, et al. Glaucoma in aphakia and
pseudophakia in the Chennai Glaucoma Study. Br J Ophthal-
mol. 2005;89:699–703.
32. Noertjojo K, Maberley D, Bassett K, Courtright P. Awareness of
eye diseases and risk factors: identifying needs for health
education and promotion in Canada. Can J Ophthalmol. 2006;
41:617–623.
33. Pfeiffer N, Krieglstein GK, Wellek S. Knowledge about
glaucoma in the unselected population: a German survey. J
Glaucoma. 2002;11:458–463.
34. Sathyamangalam RV, Paul PG, George R. et al. Determinants of
glaucoma awareness and knowledge in urban Chennai. Indian
J Ophthalmol. 2009;57:355–360.