Assessment of knowledge of glaucoma treatment during pregnancy: A survey based- study

Ghadeer Al-Humimat MD, Mohannad Q. Albdoor MD Ibtisam Marashdeh MD1, Duaa Daradkeh MD , Mohammad Alnsour MD .

ABSTRACT

Aim:To explore the preexisting knowledge among a sample of ophthalmologists in Jordan toward the treatment of glaucoma in pregnant patients.

Method: A self-administered online survey, using a 17-item questionnaire, which was distributed via email or social media between February and June 2021 among ophthalmology specialists, ophthalmology residents, and glaucoma specialists in Jordan. The data that were collected: demographic data, clinical experience, and assessment of knowledge about the United States Food and Drug Administration (FDA) classification of antiglaucoma medications. Data from the respondents were analyzed and reported.

Results: A total of 182 questionnaires were sent out and 100 (response rate = 55%) were returned. Of these, 71% had dealt with pregnant glaucoma patients, with 56% referring the patients to glaucoma clinics, 27% asking a colleague, 9% acting based on the preexisting knowledge and 8% using online medical resources. Nearly half of the respondents were wrong about or unsure of the FDA categories of the various antiglaucoma classes.

Conclusion: This survey demonstrated the lack of knowledge among some ophthalmologists which may be due to a lack of guidelines, highlighting the importance of spreading awareness of such clinical situations.

Key words: antiglaucoma medications, brimonidine, glaucoma, pregnant.

JRMS April 2024; 31 (1): 10.12816/0061751

INTRODUCTION

Glaucoma is a progressive optic neuropathy characterized by a loss of retinal ganglion cells and their axons, leading to characteristic changes in the optic disc, and resulting in visual field defects. [1] Glaucoma is the leading cause of irreversible blindness worldwide, affecting around 76 million people. [2] Generally, glaucoma affects people older than 40, [2] but it may occur in younger age groups as well as in young females in their reproductive years.

These women may have certain types of glaucoma that began in childhood (such as congenital glaucoma) or secondary glaucoma (i.e., uveitic glaucoma, rubeotic glaucoma, etc). [3] There is limited data regarding the percentage of glaucoma in those younger than 40 years; however, younger patients may be detected because of enhanced awareness and the introduction of new diagnostic tools. The focus of glaucoma and pregnancy is not limited by younger age only as more women are starting their families later in life and as reproductive technology advances are helping in this. [4]

The treatment of glaucoma during and around pregnancy is considered a challenge because of the high importance avoiding visual loss of the mother by adequate maternal treatment of glaucoma and balancing that with the safety of the fetus. [4] None of the available ocular hypotensive medications is definitely safe in pregnancy. The only antiglaucoma medications available in Category B (Presumed safety based on animal studies, but no human studies) are topical alpha agonists [Table II]. [5] Other ocular hypotensive medications, such as topical beta-blockers, prostaglandin analogs, topical and oral carbonic anhydrase inhibitors, and parasympathomimetics fall under Category C (Uncertain safety, with no human studies and animal studies showing adverse effects). [5] This will pose a dilemma for the general ophthalmologists treating glaucoma in pregnant women. [3,4]

The guidelines of treating glaucoma in pregnancy are not established yet. We hypothesized that there might be a lack of knowledge among ophthalmologists regarding treating pregnant patients suffering from glaucoma. The aim of this study is to explore the preexisting knowledge among a sample of ophthalmologists in Jordan regarding the treatment of glaucoma during pregnancy.

After obtaining approval from the Royal Medical Services` ethical and research committee, a questionnaire was sent ,between February and June 2021, via email and social media to ophthalmology residents and specialists, identified by Whatsapp groups that included ophthalmology residents and specialists in Jordan. These social groups were created by consultant ophthalmologists to ease scientific communications and spread knowledge.

They were asked to provide the following data:

demographic data (age, sex, and place of work), clinical experience (medical degree, duration of practice, and the exposure to pregnant glaucoma patients who were treated during their clinical practice), and assessment of knowledge regarding the classification of various antiglaucoma eye drops during pregnancy. Further, they were asked about their management of the first pregnant glaucoma patient during their practice.

An email address was a required field in the questionnaire to avoid duplicity and guarantee the transparency of information. Regarding the scoring system, a score of zero was given for wrong answers and a score of 1 to the right answer with a total score of 10/10. Then the results were grouped into 3 groups (Poor 36%, fair 33%, good 31%). These groups were created statistically using percentiles.

Results

182 confirmed receiving of the questionnaire, but 100 (response rate = 55%) were returned. Demographic data are shown in (table 1).Of these, 66% were males and 34% were females. Fifty percent of the respondents were between 31 and 35 years old. The 100 respondents included 57 % ophthalmology specialists, 37% ophthalmology residents and 6% glaucoma specialists.

Of the 100, 71% had faced a pregnant glaucoma patient. When they were asked “What would you do if you had a pregnant glaucoma patient in your clinic for the first time?”, they responded as follows:

*I will refer the patient to a glaucoma specialist. (56%)

*I will ask a colleague if I think he/she has the required knowledge. (27%)

*I will act based on my preexisting knowledge toward treating glaucoma in pregnancy. (9%)

*I will use the online resources and act accordingly. (8%)

The certainty about the safety of antiglaucoma medications in pregnant patients was unclear. Around half of the respondents were unaware or wrong about the FDA classification of the major classes of ocular hypotensive medications (Figure 1).

Figure 1: Response toward FDA classification of major classes of antiglaucoma medications. FDA; US Food and Drug Administration.

Table I: The demographic data of the respondents to our questionnaire.

Table.I: Demographic data
sex:		Percentage (%)
	male	66
	female	34

Age		Frequency
	25-30	26
	31-35	50
	36-40	16
	41-45	4
	>45	4
Duration of practice		Frequency
	1 - 5 years	56
	6-10 years	27
	11-15 years	10
	>15 years	7
Place of work:		Frequency
	Jordan Royal medical services	85
	MInistry of health	10
	private sector	5
Physician medical degree:		Frequency
	Resident (junior)	16
	Resident (Senior)	21
	Specialist (general ophthalmology)	57
	Specialist (glaucoma specialist or fellow)	6

Table II: The Food and Drug Administration Classification for antiglaucoma medications

Class of anti-glaucoma	Evidence	Category
----	Medications that have strong evidence of safety, based on human studies	Category A
Alpha‑agonist	Medications that have varying human and animal data. For example, a drug is graded as Class B if animal studies showed some harm but human studies indicated safety, or if animal studies have shown safety but no human studies were available	Category B
Topical beta-blockers, prostaglandin analogs, topical and oral carbonic anhydrase inhibitors, and parasympathomimetics	Describes medications that showed side effects in animal models, or where inadequate animal and human studies were available	Category C

Discussion

The challenge of treating glaucoma in a pregnant patient is balancing the risk of ocular hypotensive medications on the baby with the risk of glaucomatous visual loss in the mother. [6] The coincidence of glaucoma and pregnancy is considered rare. [6] However, our study showed that 71% of the respondents had faced a pregnant glaucoma patient. A study held in the UK showed that 26% of consultant ophthalmologists had previously treated pregnant women with glaucoma. [7] The difference in the results may be due to a different sample of respondents, as we included residents. Further, we have to establish the fact that there are higher number of pregnant women in our region. The total fertility rate (TFR) measures the average number of children per women (usually referring to women aged 15 to 49 years). [8, 9] According to the Jordan population and family health survey (JPFHS), conducted by the department of statistics (DoS), the TFR was 2.7 in 2017-2018. [10] On the other hand, the TFR in UK was 1.82 in 2014. [11] A more recent data has been released for England and Wales that reported a TFR of 1.7 in 2018. [12] This number fell to 1.58 in 2020. [12] In addition, if in the same institute, one pregnant patient with glaucoma might be seen by many ophthalmologists in the same clinic on many occasions during her pregnancy. This is the reason why we have 71% vs 26% in UK.

Several ocular hypotensive drugs may be harmful to the fetus with no clear guidelines for how to use antiglaucoma medications during pregnancy and the postpartum period. [13,14] The rare coincidence of glaucoma and pregnancy impede large clinical trials and large systemic studies. The available knowledge is derived from few published case reports or animal studies. Insufficiency of data make the ophthalmologists unsure about managing glaucoma in a pregnant patient. [15] Furthermore, the availability of glaucoma specialists in our country, who provide the proper management for the patients, may encourage ophthalmologists to refer the patients to glaucoma specialist.

The lack of clear guidelines and the scarcity of studies that investigate the safety of antiglaucoma medications render the ophthalmologists confused about treating pregnant glaucoma patients. [15] As shown in (Figure 1), the responses regarding the FDA classification of the major classes of ocular hypotensive medications were as following: betablockers (62% right and 38% wrong), prostaglandin analogues (58% right, and 42% wrong), carbonic anhydrase inhibitors ( 52% right, 48% wrong) and sympathomimetics -brimonidine (58% right, and 42% wrong). In Vaideanu’s survey, 34% were unsure of how to deal with this clinical situation. [7] The lower percentage, which has been reported in Vaideanu’s survey, could be related to the type of respondents who were consultant ophthalmologists in UK, identified from the Medical Directory and internet database search.

The limitation of our study regards the questionnaire design. The health surveys have been an important source of knowledge; however, bias is considered a pervasive issue in a questionnaire survey. [16] The bias may be related to the individual questions, the whole questionnaire and how the survey is administered. [16] The response rate to our questionnaire was 55%, which is good. [7] As the use of the questionnaire design is increasing to assess the physicians' knowledge and attitudes, so the response rates among them are dropping. [17] The reasons for this include, among others; the lack of knowledge, lack of relevance of the research, the survey method, and lack of time. [17] The average response rates based on the survey method were 57% (in person survey), 50% (mail survey), 30% (email survey), 29% (online survey), 18% (telephone survey), and 13% (in app survey). [18] The overall average response rate of the aforementioned percentages was 33%. [18]

Conclusion

The treatment of glaucoma in a pregnant patient is challenging. Most of our ophthalmologists in this survey had faced a pregnant glaucoma woman. However, our survey demonstrated that the lack of knowledge among some ophthalmologists may be due to a lack of a clear treatment paradigm, which highlights the importance of establishing guidelines for treating such clinical situations.

Abbreviations

FDA: Food and Drug Administration.

TFR: Total Fertility Rate.

References

1. European Glaucoma Society, Terminology and Guidelines for Glaucoma, 4th edition, 2015, available at http://www.icoph.org/dynamic/attachments/resources/egs_guidelines_4_english.pdf

2.Tham YC, Li X Wong TY, Quigley HA, Aung T, Cheng CY. Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology. 2014.; 121(11): 2081-2090.

3. Salim S. Glaucoma in pregnancy. Curr Opin Ophthalmol 2014;25:93‑7.

4.Sethi HS, Naik M, Gupta VS. Management of glaucoma in pregnancy: risks or choices, a dilemma?.Int J Ophthalmol. 2016; 9(11): 1684–1690. doi: 10.18240/ijo.2016.11.24

5.Senthil S, Cheriyath D. Glaucoma in pregnancy: An update and practical guide. Kerala J Ophthalmol. 2021;33:8-11.

6.Razeghinejad MR. Glaucoma medications in pregnancy. Oman J Ophthalmol. 2018;11(3):195-199. doi:10.4103/ojo.OJO_212_2017

7.Vaideanu, D., Fraser, S. Glaucoma management in pregnancy: a questionnaire survey. Eye 21, 341–343 (2007). https://doi.org/10.1038/sj.eye.6702193

8.Max Roser (2014) - "Fertility Rate". Published online at OurWorldInData.org. Retrieved from: 'https://ourworldindata.org/fertility-rate' [Online Resource]

9.World Health Organization. Total fertility rate (per woman.)[Internet]. Cited 2022. Available from: https://www.who.int/data/gho/indicator-metadata-registry/imr-details/123

10. Department of statistics. Jordan Population and Family Health Survey 2017-18. [Internet] March 2019. Available from: http://dosweb.dos.gov.jo/dr-al-zoubi-launch-of-the-key-indicators-report-for-the-jordan-population-and-family-health-survey-jpfhs/

13.Razeghinejad MR Md, Masoumpour M Md, Eghbal MH Md, Myers JS Md, Moster MR Md. Glaucoma Surgery in Pregnancy: A Case Series and Literature Review. Iran J Med Sci. 2016;41(5):437-445.