Research Article | Open Access

Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong

*Corresponding author: Sunny Chi Lik Au, Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong

Abstract

---

Objective: Blindness caused by mature cataract is reversible with timely cataract extraction surgery, however neglecting it could complicate with phacomorphic glaucoma. This study aims to investigate the psych socioeconomic determinants of phacomorphic glaucoma complicated and uncomplicated mature cataracts in Hong Kong.
Participants and Methods: Retrospective review of cataract surgery records from 2013 - 2018 in a tertiary public emergency hospital’s ophthalmology unit in Hong Kong was done to identify phacomorphic glaucoma and uncomplicated mature cataract patients as case and control respectively. Data on demographics, psychiatric diseases, social and economic factors were extracted and analyzed.
Results: 36 cases and 39 controls were included, with similar age (p = 0.73) and sex (p = 0.99). Presence of psychiatric diseases (p = 0.02) and absence of spouse (p = 0.008) were associated with phacomorphic glaucoma in univariate logistic regression analysis. Intention to private healthcare service usage (p = 0.002, p = 0.006) and living out of public rental housing (p = 0.002, p = 0.004) were associated with phacomorphic glaucoma in both the univariate and multivariate logistic regression analysis.
Conclusion: Attention to screening of mature cataract before complication of phacomorphic glaucoma occurs should target the single elderly households, psychiatric patients, and the non-public housing population.
Keywords: Socio economic factors, Psychiatry, Blindness, Cataract, Glaucoma
Abbreviations: IOL: Implantation of Intraocular Lens, ECCE: Extracapsular Cataract Extraction, eHRSS: Electronic Health Record Sharing System, OAH: Old Age Home, CSSA: Comprehensive Social Security Assistance

Background

---

Progressing with age, the natural lens of the eye would lose transparency and thicken, progressing from immature to mature cataract. Mature cataract is defined by significant opaque lens that prevent visualization of the posterior lens capsule, yet in time cataract surgery could reverse blindness by such [1]. Mature cataract does not only decrease visual acuity and cause blindness, but also complicate with phacomorphic glaucoma. “Phacomorphic” implies the disease is cataract lens related, and “glaucoma” is an irreversible optic neuropathy comes with visual field defect [2]. Phacomorphic glaucoma usually presents with acute onset of eye pain, and is often associated with headache, nausea or vomiting; thus, calling for an emergency department attendance. For patients with mature cataracts, lens extraction surgery with implantation of intraocular lens (IOL) is the definitive treatment to restore vision [3,4]. In modern countries, mature cataracts usually happen on self-neglecting, socially isolated or low socioeconomic class of patients. This study aims to investigate the psychosocioeconomic determinants of complicated (phacomorphic glaucoma) and uncomplicated mature cataracts in Hong Kong.

Methods:

---

Patients were screened from the cataract operation records of a tertiary public emergency hospital’s ophthalmology unit via the electronic system with the ICD-9 diagnosis code of 365.59 (phacomorphic glaucoma) and 366.17 (mature cataract). Cataract surgery cases in the 5 years of 2013 - 2018 were retrospectively reviewed. Exclusion criteria was patients who were too ill or fragile to be operated for their mature cataracts. Phacomorphic glaucoma patients who underwent any kinds of cataract extraction surgery were all included. Uncomplicated mature cataract patients with visual acuity down to hand movement or below, who underwent extracapsular cataract extraction (ECCE) in the same period, were included as the control group. Data on patients’ demographics were extracted from the admission nursing summary. Medical history of psychiatric disease, smoking status, and active follow-up in other specialties before first seen by ophthalmologist were recorded. Details of psychiatric diseases were reviewed. Social factors including presence of spouse, type of housing; and economic factors of self-payment of IOL, eligibility to free public healthcare service, and intention to private healthcare usage were retrieved. Intention to private healthcare usage was measured according to patient’s registration to the electronic health record sharing system (eHRSS), which was a voluntary scheme started in 2009, that allowed free passage of patients’ electronic record between the public and private doctors whom they were under care [5]. Statistical analyses by T-test, Chi-square test, univariate and multivariate logistic regression analysis were done by SPSS version 25. (IBM, Armonk, NY, USA)

Results:

---

A total of 75 patients were identified, with 36 phacomorphic glaucoma patients and 39 uncomplicated mature cataract patients. 100% data were available for all items from the admission nursing summary. Age (p = 0.73) and sex (p = 0.99) were not significantly different, but female was uniformly more dominant in our study over both groups. Prevalence of each parameter was listed out in Table 1.

  Table 1: Characteristics of patients.

  Table 2: Details of psychiatric diseases of recruited subjects.

  Table 3: Univariate logistic regression analysis.

Significant p-values were highlighted with *
† OAH = Old Age Home, eHRSS ‡ = electronic health record sharing system

In multivariate logistic regression analysis, presence of spouse and psychiatric diseases became not associated, while eHRSS registration (p = 0.006) and public rental housing/ OAH (p = 0.004) remain significant. (Table 4)

Discussions

---

Phacomorphic glaucoma usually presents as acute intraocular pressure rise that gives the symptoms of eye redness, blurring of vision, eye pain, headache, and nausea [6]. Thus, our study setting over an emergency hospital-based ophthalmology unit was the suitable places for capturing these cases. As the name implies, phacomorphic glaucoma is caused by the diseased lens, which becomes thicker and bulkier with age and cataract progression [7]. Before the acute attack, the mature cataract usually would have a significant impact on the patient’s vision [8]. This study helps to identify the associated factors on those vision-neglecting patients, thus guiding future healthcare resources allocation or directions of screening program.
Spouse was chosen as the social factor because children don’t often live with their elderly parents in the nuclear family structure in Hong Kong. Public rental housing/ OAH were covered by the government’s safety net, but with asset and income limits subject to approval. In contrast, patients under the comprehensive social security assistance (CSSA) scheme, and civil servants were entitled for free public healthcare service, together with free IOL during cataract surgery.
Going through the economic determinant of diseases, employment status and personal income were commonly mentioned, [9, 10] yet not applicable to our study as the diseased subjects were on average over 70 years old, of post-retirement age in Hong Kong. In terms of social factor, [11] education level was not included in our analysis due to the non-structured educational system dated many decades back in the past, and possible bias from recalling difficulties by the elderly. Therefore, only relevant determinants were included in this study for better reflection of the patients’ socioeconomic status.

  Table 4: Multivariate logistic regression analysis.

Significant p-values were highlighted with *
† OAH = Old Age Home, ‡ eHRSS = electronic health record sharing system

Our study showed that age and gender were not associated with the awareness of mature cataract, despite more female underwent cataract surgery in our hospital. This could be explained by the longer life-expectancy of female in Hong Kong [12]. Out of expectation, free healthcare service and active follow-up in public hospitals were not associated, whereas intention to private healthcare usage was associated with phacomorphic glaucoma. These findings suggested that patient’s initiative to seek relevant subspecialty consultation was far more important than their financial consideration, which may be specific to eye diseases only [13]. The importance of getting motivation to seeking medical advice for illness was further evidenced by the positive impact of having a spouse, [14] and negative outcome in psychiatric disease group, whom they were prone to self-neglect [15, 16].
Interestingly, only housing factor and intention to private healthcare usage were associated, but oppositely, in the multivariate logistic regression analysis. The retrieval process of eHRSS data was retrospectively done in 2019 without knowing their exact year of eHRSS registration, thus putting an intrinsic bias, but also a new angle, in interpretation of the result. The association with phacomorphic glaucoma could be a reflection of increased self-health awareness after the disease episode, or intention to private healthcare usage after having cataract operation in the public hospital. In addition, the aforementioned bias was supplemented by the item of “Active follow-up in other specialties before first seen by ophthalmologist”, which unluckily was not associated in any analysis.
Less public rental housing/ OAH patients presented with phacomorphic glaucoma could be explained by the good community support in public housing estate or OAH on one hand, while this group of patients should have better awareness of social welfare coverage in Hong Kong throughout their application process. With the knowledge on the association of psych socioeconomic determinants of complicated mature cataract in Hong Kong, we understand more on the ophthalmology service gap in the community. Other than community medicine practitioner, geriatricians, psychiatrist could also help to do one step further as a holistic care for their patients.

Conclusions

---

Psych socioeconomic determinants of complicated mature cataract were identified. The direction of future community screening or caring programs for mature cataract should target those single elderly households, psychiatric patients and the non-public rental housing/ OAH population.
SCLA is contributed to (1) concept or design, (2) acquisition of data, (3) analysis or interpretation of data, (4) drafting of the manuscript, and (5) critical revision for important intellectual content. CKLK is contributed to (5) critical revision for important intellectual content.
All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.
Conflicts of Interest: All authors have disclosed no conflicts of interest.
Declaration: The research has not been presented, published, or posted online before, in whole or in part
Funding/support: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Ethics approval: Patients were all consented for the use of their clinical data for analysis upon signing the written consent before the surgery.
Acknowledgement: Nil
No work resembling the enclosed article has been published or is being submitted for publication elsewhere. We certify that we have each made a substantial contribution so as to qualify for authorship and that we have approved the contents. We have disclosed all financial support for our work and other potential conflicts of interest.

References

---

1. Michon JJ, Lau J, Chan WS, Ellwein LB. (2002) Prevalence of visual impairment, blindness, and cataract surgery in the Hong Kong elderly. Br J Ophthalmol. 86(2): 133-139. [PubMed.]
2. Azhany Y, Hemalatha C, Nani D, (2013) Rosediani M, Liza-Sharmini A. Sequelae of neglected senile cataract. Malays Fam Physician. 8(1): 33-37. [Ref.]
3. Ramakrishanan R, Maheshwari D, Kader MA, Singh R, Pawar N, et al. (2010) Visual prognosis, intraocular pressure control and complications in phacomorphic glaucoma following manual small incision cataract surgery. Indian J Ophthalmol. 58(4): 303-306. [PubMed.]
4. Moraru A, Pînzaru G, Moţoc A, Costin D. (2017) Functional results of cataract surgery in the treatment of phacomorphic glaucoma. Rom J Ophthalmol. 61(3): 202-206. [PubMed.]
5. Chan AY. (2014) Hong Kong] health database in Hong Kong. Japan Med Assoc J. 57(4): 185-186. [PubMed.]
6. Kaplowitz KB, Kapoor KG. (2012) An Evidence-Based Approach to Phacomorphic Glaucoma. J Clinic Experiment Ophthalmol. S1: 006. [Ref.]
7. Papaconstantinou D, Georgalas I, Kourtis N, Krassas A, Diagourtas A, et al. (2009) Lens-induced glaucoma in the elderly. Clin Interv Aging. 4: 331-336. [Ref.]
8. Gogate P, Wood M. (2008) Recognizing 'high-risk' eyes before cataract surgery. Community Eye Health. 21(65): 12-14. [Ref.]
9. Buchanan D, Gubrium A, Scott L, Douglas H Jr. (2018) The cascade of social determinants in producing chronic disease in low-income African American men. Int J Qual Stud Health Well-being. 13(1): 1549920. [Ref.]
10. Chung RY, Mercer S, Lai FT, Yip BH, Wong MC, et al. (2015) Socioeconomic Determinants of Multimorbidity: A Population-Based Household Survey of Hong Kong Chinese. PLoS One. 10(10): e0140040. [Ref.]
11. Shankar J, Ip E, Khalema E, Couture J, Tan S, et al. (2013) Education as a social determinant of health: issues facing indigenous and visible minority students in postsecondary education in Western Canada. Int J Environ Res Public Health. 10(9): 3908-3929. [Ref.]
12. Zheng Y, Chang Q, Yip PSF. (2019) Understanding the Increase in Life Expectancy in Hong Kong: Contributions of Changes in Age- and Cause-Specific Mortality. Int J Environ Res Public Health. 16(11): 1959. [PubMed.]
13. Wang MP, Viswanath K, Lam TH, Wang X, Chan SS. (2013) Social determinants of health information seeking among Chinese adults in Hong Kong. PLoS One. 8(8): e73049. [Ref.]
14. Ward PR, Mamerow L, Meyer SB. (2013) Identifying vulnerable populations using a social determinants of health framework: analysis of national survey data across six Asia-Pacific countries. PLoS One. 8(12): e83000. [Ref.]
15. Lien C, Rosen T, Bloemen EM, Abrams RC, Pavlou M, et al. (2016) Narratives of Self-Neglect: Patterns of Traumatic Personal Experiences and Maladaptive Behaviors in Cognitively Intact Older Adults. J Am Geriatr Soc. 64(11): e195-e200. [PubMed.]
16. Lamkin J, Nguyen PT, Coverdale JH, Gordon MR. (2017) Towards a Definition of “Self-Neglect” in Psychiatric Patients: Descriptions of a Case Series. Psychiatr Q. 88(3): 553-560. [Ref.]