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June 2012 International techniques and technology February 2011 EW FEATURE 47 maintained, and [they] become free of drugs." Saudi Arabia Glaucoma specialists in Saudi Arabia have not one but two types of glaucoma to contend with: primary congenital (PCG) and primary angle- closure (PACG). Literature states that 40% of glaucoma patients in Saudi Arabia have PACG, and one out of every 2,500 children is born with PCG. Most pediatric glaucoma pa- tients "undergo surgery because they aren't the best candidates for med- ical treatment," said Ibrahim Jadaan, M.D., chief, glaucoma division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. "We go directly to surgery for patients that present soon after birth, right after birth, and up to 1 or 2 years of age. We do surgery really early in those cases." Because of the severity of the disease, the most accepted surgical treatment for PCG in Saudi Arabia is a combined trabeculotomy and trabeculectomy. Regretfully, pediatric patients typically don't do well, even with early intervention. "Many patients need two or three procedures," Dr. Jadaan said. "Even with the two or three proce- dures they continue to have high pressures and go onto other proce- dures like tube implants." For PACG patients, medical in- tervention with a laser iridotomy is the first-line therapy. Unlike in the West, though, prostaglandins are not always the go-to drug because of their limited availability. "Often, we'll use a beta blocker," said Deepak Edward, M.D., director of research, King Khaled Eye Special- ist Hospital. "[Prostaglandins] are available in hospitals, but if a pa- tient is coming from a distance from a small town or village, they're not easily available in those areas." Nepal Nepal faces significant developmen- tal challenges unique to the coun- try's mountainous landscape and unpredictable climate. Only 43% of the country has access to all-weather roads, according to the World Bank, which greatly impairs the popula- tion's access to healthcare facilities. A 2011 United Nations report ranked Nepal 157 out of 187 countries based upon its human development index, factoring in life expectancy and standard of living. "The majority of my newly diag- nosed glaucoma patients present in the advanced stage of disease," said Suman Thapa, M.D., head, Nepal Glaucoma Eye Clinic. "They are poor and unable to afford medica- tions and sometimes even have to travel several days to avail treat- ment. Thus my first-line of therapy is surgery most of the time. For open-angle glaucoma, trabeculec- tomy is the treatment of choice, and for angle-closure glaucoma, [it's] trabeculectomy combined with lens removal." Surgical treatment is typically successful, said Dr. Thapa, allowing the patient to be off of medications completely. "The disadvantage is that imme- diately after trabeculectomy the vision can deteriorate although the eye pressure is controlled," he said. "Many patients develop a cataract a few years later. Therefore if there is an associated early cataract, a com- bined procedure works well. "Results of cataract extraction in early cases of angle closure are excel- lent," he continued. "The results of phaco-trabeculectomy are promis- ing, too, and [it] is probably the best operation for glaucoma in our re- gion. We are now looking into eval- uating the results in a prospective study." For open-angle glaucoma, though, medications are a realistic possibility. Like glaucoma specialists in Saudi Arabia, Dr. Thapa prefers beta blockers because the cost of the medicine is less compared with other alpha agonists and prostaglandin analogues. "The majority of them do well with the drug, however some de- velop resistance to the medications and have to be changed to another glaucoma drug," Dr. Thapa said. EW References Abu-Amero KK, Edward DP. Primary Congeni- tal Glaucoma. 2004 Sep 30 [Updated 2011 Aug 25]. In: Pagon RA, Bird TD, Dolan CR, et al., editors. GeneReviews [Internet]. Seattle (WA): University of Washington, Seattle; 1993. Abu-Amero KK, Gonzalez AM, Osman EA, Lar- ruga JM, Cabrera VM, Al-Obeidan SA. Suscep- tibility to primary angle closure glaucoma in Saudi Arabia: the possible role of mitochondr- ial DNA ancestry informative haplogroups. Molecular Vision. 2011;17:2171-2176. Thapa SS, Kelley KH, Rens GV, Paudyal I, Chang L. A novel approach to glaucoma screening and education in Nepal. BMC Ophthalmology. 2008, 8:21. Editors' note: The doctors mentioned have no financial interests related to this article. Contact information Edward: dedward@kkesh.med.sa Giorgis: abebatgiorgis@yahoo.com Jadaan: ialjadaan@yahoo.com Thapa: sumansthapa@yahoo.com Poll Size: 377 EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send a 4-6 question online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the current 1,000+ physicians who take a minute a month to share their views, please send us an email and we will add your name. Email ksalerni@eyeworld.org and put EW Pulse in the subject line; that's all it takes. Copyright EyeWorld 2012