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In contrast, Bedri and Alemu, evaluated glaucoma patients specifically for the prevalence of exfoliation in Addis Ababa. Of 432 patients, 108 (25%) had exfoliation[14]. In addition, Teshome and Regassa studied the prevalence of exfoliation in 229 cataract surgery patients in Addis Ababa and 39.3% had exfoliation.[15] The mean age of these patients was 63.7 years and the authors thought the syndrome was presenting in patients younger than typical for Europe.
Unfortunately, little information is available regarding the types of glaucoma or treatment patterns in Ethiopia regionally or among specific ethnic or religious groups. The purpose of this survey was to evaluate the prevalence of the type of glaucoma, treatment patterns and patient attitudes towards community support systems based on ethnicity and religion in Ethiopia.
Primary openangle glaucoma was the most prevalent type of glaucoma found in this study. However, a clinically important minority of patients demonstrated several types of glaucoma found primarily in other parts of the world. Exfoliation glaucoma was noted in 17%. This finding was fairly consistent with the findings of Bedri and Alemu (25%), but was lower than found by Teshome and Regassa (39%)[14, 15]. However, we did not evaluate a specific cataract surgical population which might have influenced the prevalence of exfoliation in our study[16]. The overall prevalence of exfoliation for Ethiopia generally appeared less than in many European countries where this type of glaucoma is common (2575%, generally in Baltic and Mediterranean countries), although it was higher than found in countries with a known low prevalence such as the United States (3%)[2]. Among individual ethnic groups evaluated in our study, the prevalence of exfoliation glaucoma was highest in the Gurage population (31%) and lowest in the Amhara/Tigre (18%) and Oromo groups (8%).
Of interest also was a 5% prevalence of chronic angleclosure glaucoma that was higher in the Amhara/Tigre (6%) and Oromo (5%) ethnic groups. Chronic angleclosure occurs at a very low percent in all populations, but is high in the Indian and Chinese populations in East Asia[17, 18]. The reason for the slightly higher prevalence of chronic angleclosure glaucoma in this study than in most world populations is not clear.
Patient characteristics were generally similar across the religious and ethnic groups. The prevalence of a positive family history for glaucoma and gender distribution was similar, while the average patient age of approximately 60 years appeared slightly younger compared to several previous reports from other parts of the world[2, 1921]. The reason for the younger age is not known exactly. However, Teshome and Regassa noted that their Ethiopian exfoliation population was younger than typically found in Western countries[15]. In addition, AfricanAmericans have been described in several previous reports as developing glaucoma earlier than Caucasians[2].
The incidence of diabetes (13%) and systemic hypertension (20%) was consistent in our patients with Western countries, while the percent with cardiovascular disease appeared low (1%)[22]. This may reflect the overall younger glaucoma populations in Ethiopia that may not have had the time to develop clinically manifest cardiovascular disease from their diabetic and hypertensive conditions.
Treatment characteristics were generally the same across the religious and ethnic groups. The number of patients in this study prescribed at least two medicines (42%) appears similar to that of other Western countries[23]. In contrast, the level of compliance may be lower than Western countries[24]. However, it must be noted that the accuracy of selfreported compliance generally is suspect.
Overall, the number of patients who received surgery for glaucoma appears higher in Ethiopia (36%) than other Western countries[25]. The reason for this is not known. Physicians in Ethiopia frequently choose surgery over medical therapy early in the clinical course, when they believe noncompliance may be a problem. In addition, patients had limited access to prostaglandins, which may have led to a greater need for surgery. Several studies have indicated that the need for surgery has decreased over the last decade where the prostaglandins have become available[26, 27]. Another factor may be that since Ethiopians are primarily of the black race, which is known to have more severe glaucoma, then surgery was more often required[2].
Regarding patient attitudes toward their support groups, generally patients had a positive image of their doctor, believed that God was positive towards them receiving treatment and had disclosed the existence of their illness to their spouse. However, their community was generally unaware of their disease.
Nonetheless, several differences in patient attitudes existed based on religious or ethnic differences. First, patients in the Amhara/Tigre tribe more often expressed that the doctor had a specific concern for them. The reason for this was unknown and did not appear to affect compliance; second, a higher percentage of Christian patients indicated the community was not aware of their disease. This was also positive by multivariate analysis. The meaning for this finding is not completely clear. The level of awareness by the community was not examined by the survey. Further, glaucoma awareness as a disease in Ethiopia appears generally low. Consequently, a person's knowledge of an acquaintance with glaucoma may be interpreted as merely ‘an eye problem’ and not this specific ocular condition.
This study suggests that the prevalence of glaucoma type varies among ethnic groups in Ethiopia with exfoliation being more common in the Gurage, and chronic angleclosure glaucoma in the Amhara/Tigre and Oromo populations. In addition, some variance in patient treatment attitudes is dependent upon religious preference and ethnicity.
This study was limited by the central geographical location within Ethiopia of Addis Ababa and the surrounding environs. Consequently, a more urban and Christian population, derived from several ethnic groups, are represented in this study. Since Ethiopia is made up of numerous ethnic groups, and is about half Muslim, future studies might concentrate on other geographic regions to capture a different ethnic profile and include more Islamic patients. Future study in Ethiopia is also needed to describe the prevalence of glaucoma among the general population, the response to treatment and glaucomatous progression rates.
Acknowledgements: We give our thanks to financial support clinically from Teleios, Inc., a private foundation.
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