Glaucoma in Mongolia

A Population-Based Survey in H\l=o"\vsg\l=o"\lProvince, Northern Mongolia

Paul J. Foster, FRCSEd; Jamyanjav Baasanhu, MD, DCEH; Poul Helge Alsbirk, MD;
Dorj Munkhbayar, MD; Davaatseren Uranchimeg, MD; Gordon J. Johnson, MD, FRCSC

Objectives: To determine the prevalence of glaucoma lence of gonioscopically occludable angles was 6.4% (64
and suspect glaucoma, and to classify the cases detected subjects, including those with glaucoma). Primary open\x=req-\
according to mechanism. angle glaucoma was diagnosed in 5 subjects (preva-
lence, 0.5%). As all these subjects were older than 60 years,
Design: A population-based prevalence study. the prevalence became 2.1% for this age group. Three cases
(prevalence, 0.3%) of secondary open-angle glaucoma
Setting: Rural and urban locations in H\l=o"\vsg\l=o"\lprov- were detected. No cases of secondary angle-closure glau-
ince, northern Mongolia. coma were diagnosed. The prevalence of blindness was
1.2% (12 subjects), and primary glaucoma accounted for
Participants: Nine hundred forty-two (94.2%) of 1000 one third of these cases (4 subjects).
individuals 40 years of age and older were examined.
Conclusions: We confirmed glaucoma as a major pub-
Main Outcome Measure: Primary angle-closure lic health problem in northern Mongolia. Primary angle\x=req-\
glaucoma was diagnosed in subjects with previous closure glaucoma is more prevalent than primary open\x=req-\
acute or angle closure and in
intermittent symptoms of angle glaucoma, supporting clinic-based data from other
individuals with an occludable angle and an intraocular east Asian countries. Among the subjects examined, 97
pressure greater than 19 mm Hg or a glaucomatous (9.7%) had either manifest, latent, or suspect glaucoma.
visual field. Neighboring populations may be similarly affected ow-
ing to a shared genetic heritage.
Results: The prevalence of manifest primary angle\x=req-\
closure glaucoma was 1.4% (14 subjects). The preva- Arch Ophthalmol. 1996;114:1235-1241

NEARLY
HALF of the world's POAG.4 In contrast, POAG rates found in
estimated 5.1 million anationwide Japanese study were approxi¬
people who are blind be¬ mately 10 times those of PACG.5 Neither
cause of glaucoma re¬ of these studies used gonioscopy or vi¬
side in east Asia.1 In the sual field testing to examine all subjects.
clinic reports from China2 and Sin¬ Consequently, the prevalence of POAG
gapore,3 a majority of the patients de¬ and PACG may be underrepresented.
scribed have primary angle-closure glau-
coma (PACG). Inferring a similar

population prevalence from these find¬ For editorial comment

From the Department of
Preventive Ophthalmology,
Institute of Ophthalmology,
London, England (Drs Foster
and Johnson); and the
Departments of
Ophthalmology, Medical
University Central Hospital,
Ulaanbaatar, Mongolia
(Drs Baasanhu, Munkhbayar,
and Uranchimeg) and Hiller\l=o/\d
Hospital, Hiller\l=o/\d,Denmark
(Dr Alsbirk).
ings can be criticized on the grounds that see page 1251
individuals with PACG may have acute or
intermittent symptoms in contrast to pri¬ Mongolia is believed to be the ge¬
mary open-angle glaucoma (POAG), hence netic center of the Sino-Mongoloid race.
leading to an overestimate of the former From here, migration occurred through¬
and an underestimate of the latter. Cong¬
out neighboring regions and also across the
don et al2 propose that this bias is avoided "Beringia" isthmus, giving rise to Native
by population-based prevalence studies,
yet, unfortunately, few of these studies
conducted in east Asia have achieved ad¬
equate levels of participation. One such See Subjects and Methods
on next page
survey in Beijing showed a high preva¬
lence of PACG and a low prevalence of

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 SUBJECTS AND METHODS
Ethical approval for this project was obtained from the Mon¬
golian Ministry of Health, Ulaanbaatar. The work was per¬
formed in accordance with the World Medical Associa¬
tion's Declaration of Helsinki. Mongolia covers an area of
1 566 500 square kilometers (604 829 square miles) (one
sixth the size of the United States) and has 2.2 million in¬
habitants, giving it one of the lowest population densities
on earth. This density is exaggerated by the fact that 40%
to 50% of the population live in cities. The country is di¬
vided into 22 provinces (aimags), which are subdivided into
districts (sums). The smallest geographical division is the
bag, which is an area roamed by a group of seminomadic
families. Of these bags, 3 to 8 surround the town at the cen¬
ter of the district; each bag has a population of approxi¬
mately 2000 people. Hövsgöl (109 200 square kilometers
[42 150 square miles]) is the most northerly province in
Mongolia. The population on May 23, 1995 was 117 587
(individuals &40 years, 20 896). The regional capital is Mo¬
ron; its population is 27 230 (individuals s 40 years, 4860).
SAMPLING
One thousand subjects aged 40 years and older were chosen
for examination (4.78% of the population of this province
in this age group). Four hundred subjects (40%) were drawn
from the aimag capital, Mörön (8.23% of its population aged
&40 years). Within the town of Mörön, subjects were se¬
lected in simple random manner within 3 of the 6 Hows (a
Horo being a city district). Three predominant ethnic groups
reside in the 24 districts of Hövsgöl. Districts (ie, sums) out¬
side Mörön were stratified according to their ethnic major¬
ity, and 1 district was chosen at random from each of the 3
groups. Two hundred people aged 40 years and older were
selected from each group. An urban group from the dis¬
trict's town and a rural group from the surrounding bags were
chosen in proportions that reflected the distribution of the
population in that district. In the town centers, simple ran¬
dom selection was used. However, in the rural communities
where random sampling would have caused insurmount¬
able logistic problems, systematic sampling was used. Start¬
ing in the bag closest to town, all residents aged 40 years and
older were identified from census data, and the entire group
was called for examination. If necessary, the process was per¬
formed again in the next nearest bags until the required num¬
ber of subjects had been examined. Selection was always
strictly determined by position on the census list. Any sub¬
jects who did not attend were not replaced by others from
further down this list. The sampling procedure is summa¬
rized in Table I.
CLINICAL ASSESSMENT
An 8-point questionnaire was used in a standard manner
by 2 Mongol ophthalmologists (D.M. and D.U.) to glean a
Americans and Inuit populations.6·7 The Inuit of Alaska,
Canada, and Greenland have been the subject of several
extensive studies.8"10 The glaucoma they suffer is pre¬
dominantly PACG, and the prevalence exceeds, to our
knowledge, those of all other populations studied. Where
POAG does occur, the prevalence is low. The disparity
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possible history of symptoms of intermittent angle clo¬
sure and a family history of blindness. Snellen visual acu¬
ity was measured with distance correction if eyeglasses were
worn. A pinhole was used if the visual acuity was less than
20/60. The central 25° visual field was assessed in all sub¬
jects using a static, semiautomated field analyzer (Henson
CFA 3000, Tinsley Medical Instruments, Croydon, En¬
gland). This device vs a more sophisticated perimeter (Hum¬
phrey Field Analyzer, Humphrey Instruments, San Lean¬
dro, Calif) is sensitive and specific for detecting moderate
and advanced glaucomatous field loss.15 A 26-point, thresh¬
old-related suprathreshold test was routinely used. If 1 or
more points were missed, this test was extended to a 66-
point test. Subjects with an equivocal or clinically glauco¬
matous field defect on suprathreshold screening were re-
examined using a 52-point threshold analysis.
All subjects underwent slit-lamp examination (model
900, Haag-Streit, Bern, Switzerland). Ischemie sequelae of
angle-closure glaucoma (eg, glaukomflecken and iris whor-
ling) and stigmata of secondary glaucomas were noted. The
intraocular pressure (IOP) was measured 3 times in each
eye using a Goldmann applanation tonometer (Haig-
Streit). The pressure in each eye was defined as the me¬
dian of the 3 readings. The optic disc and the posterior pole
were examined using a +90 diopter (D) lens (Volk, Men¬
tor, Ohio) through the undilated pupil. If a satisfactory view
was not obtained or if an inexplicable field defect was de¬
tected, the pupil was dilated with 0.5% tropicamide (Al¬
con Laboratories [UK], Watford, England) after gonios-
copy, provided the angle was not judged to be occludable.
The vertical cup-disc ratio was judged by observing disc
contour (when a stereoscopic view was obtained) and an¬
gulation of blood vessels that crossed the disc rim. Stan¬
dard photographs and measurement graticules were not
used. Disc hemorrhaging or notching (ie, localized tissue
loss at the superior or inferior pole) was recorded. The fi¬
nal classification of a disc as glaucomatous did not require
a specific minimum neuroretinal rim width or cup-disc ra¬
tio value.
Gonioscopy was performed in all patients with the use
of a Goldmann gonioprism. The drainage angle was graded
as occludable or as open, as defined in the "Diagnostic Cri¬
teria" subsection of our "Subjects and Methods" section.
A 4-point classification was used to record the overall iris
profile as steep, angulated, regular, or concave; the grade
chosen best reflected the entire 360° architecture. This
scheme differed from that of Spaeth16 only in that subjects
with a Spaeth grade of "s" (ie, a steep peripheral iris pro¬
file) were divided into 2 groups. Subjects in the first group
had a typical steep, convex iris profile with little diver¬
gence between the iris and the corneosclera and a cen¬
trally shallow anterior chamber. Subjects in the second group
had an iris that rose steeply from its insertion but then made
an abrupt angulation away from the corneoscleral wall, re¬
sulting in a relatively deep axial anterior chamber and a cen¬
trally flat iris plane. This division allowed the identifica¬
tion of subjects with a plateau iris configuration, in whom
in the prevalence of PACG between the Inuit and whites
has been attributed to the shallow anterior chamber found
in the former. Among 2 studies of anterior chamber depth
in the Chinese (in whom PACG prevalence is believed
to be higher than in white populations), only 1 found
mean values substantially less than in whites."12
 prophylaxis and treatment of angle closure may be differ¬
ent from that in cases predominantly attributable to pupil
block. Manipulative gonioscopy with a Goldmann-style
2-mirror lens (Clement Clarke International, Harlow, En¬
gland) or indentational gonioscopy with a 4-mirror lens
(Clement Clarke International) was used (unless the angle
was wide open) to detect peripheral anterior synechiae,
which were graded as present or absent in each quadrant.
If excess pigment was seen on the superior trabecular mesh¬
work, it was recorded. In subjects with an occludable angle
but no stigmata of angle closure (ie, a normal IOP, a nor¬
mal disc and field, with no iris or lens ischemie sequelae,
symptoms, or peripheral anterior synechiae), a dark-
prone provocation test was performed in which the sub¬
jects laid face down with their eyes closed and bandaged
for an hour, with care taken to avoid pressure on the globe.
A rise in the IOP of 8 mm Hg or more was considered to
be a positive result.
All slit-lamp examinations (including optic disc evalu¬
ation), tonometry, and gonioscopy were performed by the
same investigator (P.J.F.), therefore eliminating any po¬
tential for interobserver error. Glaucoma or glaucoma sus¬
pect cases among the first 350 subjects were also exam¬
ined by a glaucoma specialist (P.H.A.) who was experienced
in the assessment of angle-closure glaucoma cases. Interob¬
server agreement between these 2 investigators for tonom¬
etry and gonioscopy was assessed.
DIAGNOSTIC CRITERIA
An occludable angle defined as an angle in which
was
the pigmented trabecular meshwork was not visible
throughout three quarters or more of the angle circum¬
ference8 in the primary position without manipulation
or indentation. Acute angle-closure glaucoma (past or
present) was diagnosed if a clear history and iris or lens
ischemie sequelae were found in conjunction with an
occludable angle in the affected eye. The diagnosis of
intermittent angle-closure glaucoma required intermit¬
tent symptoms, including nocturnal visual blurring, ocu¬
lar pain, and the presence of halos, in a subject with an
occludable angle. An eye with an occludable angle that
exhibited either a raised IOP (>19 mm Hg) or a glauco¬
matous field defect with consistent damage to the optic
nerve was classified as having chronic angle-closure
glaucoma. We chose 19 mm Hg as the upper limit of
normal for IOP measurements by using the mean ( + 2
SDs) of the measurements obtained from the studies of
the Eskimos8 and the Chinese.4 Definite glaucomatous
field defects were defined as having a nerve fiber bundle
pattern that was at least 5 dB below threshold and at
least 10° wide. If smaller or less dense but still a typical
nerve fiber bundle pattern, the defect was classified as
probably glaucomatous. Equivocal field defects, or those
typical of other diseases, were classified as nonglauco-
matous. If none of the characteristics described were
present but an eye with an occludable angle had either
However, differing methods of measurement were used in
these studies, meaning that the results may not be compa¬
rable. Plateau iris configuration is believed to be a com¬
mon feature among east Asians,13 offering another pos¬
sible explanation for this unexpected finding.
A previous survey14 of visual morbidity in Mongo-
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peripheral anterior synechiae, excess pigment deposits
on the superior trabecular meshwork, a positive result
on the provocation test, or was the fellow of an eye with
acute, intermittent, or chronic angle closure, the diagno¬
sis was termed latent angle closure. All other subjects
with occludable angles were classified as angle-closure
suspects. The causes of secondary angle closure, such as
rubeosis or lens intumescence, were sought.
Open-angle glaucoma was diagnosed if a definite or
probable glaucomatous field defect and corresponding dam¬
age of the optic nerve were present in an eye without an
occludable drainage angle. If a precipitating factor, such
as pseudoexfoliation or evidence of severe previous intra¬
ocular inflammation, could be identified, the condition was
termed secondary open-angle glaucoma; otherwise, the term
primary was applied. Subjects with a disc appearance sug¬
gestive of glaucoma (eg, notching or disc margin hemor-
rhaging) but without characteristic field loss were termed
open-angle glaucoma suspects.
The World Health Organization's definition of blind¬
ness, which is a visual acuity of less than 20/400 (3/60) or
a visual field of less than 10°, was used; subjects whose vi¬
sual acuities or visual fields were within these ranges were
classified as either blind or unilaterally blind. The cause of
blindness was classified as the pathological process con¬
sidered responsible for the majority of the visual loss. Cata¬
racts of grade 3 or 4 (classification by Baasanhu et al14), de¬
generative or uncorrected high myopia with an axial length
of greater than 26 mm, posterior pole staphyloma and a re¬
fraction of greater than 6 D, grades 3 and 4 climatic drop¬
let keratopathy (classification by Gray et al17), and macu¬
—
lar degeneration exhibiting gross disciform scarring in a
subject older than 80 years were all accepted as causes of
blindness.
MANAGEMENT OF GLAUCOMA
Any subject who had glaucoma or who was at risk of con¬
tracting glaucoma was given advice, medication, and re¬
ferral for further management; subjects who had manifest
or latent PACG were treated in the field with a portable YAG
laser (Visulas II, Carl Zeiss Ltd) to produce a peripheral
iridotomy. When necessary, arrangements were made for
patients to undergo filtration surgery.
DATA ANALYSIS
Validated double data entry from the specifically designed
proforma was performed in London, England. Data were
analyzed using a statistical software package for the social
sciences (SPSS Ine, Chicago, 111) on personal computers.
Proportions were compared using the 2 and Fisher exact
tests. Confidence intervals were calculated using custom
software that corrected for design effect and sampling
fraction. These calculations were based on the assumption
that simple random sampling was used throughout each
cluster.
lia found that 35% of the blindness in the population aged
40 years and older was due to glaucoma. Other major
causes of blindness are cataract and climatic droplet kera-
topathy (36% and 7%, respectively). We were, there¬
fore, interested in determining the nature of glaucoma
in Mongolia because of the high proportion of ocular mor-
 Table 1. Details of Sample Size and Selection
Bags or
Horos*
Population Sample Sampled/ Sample
Location 40 y Size Total Method
Mörön
Provincial capital 4860 400 3/6 Horos Simple random
Tunel
Center 191 66 1/1 Horn Simple random
Rural 394 134 2/6 Bags Systematic
Gait
Center 157 36 1/1 Horn Simple random
Rural 731 164 2/6 Bags Systematic
Renchinlhumbe
Center 182 58 1/1 Horn Simple random
Rural 441 142 4/6 Bags Systematic
*Bag is an area occupied by a group of nomadic families; Horo, an urban A frequency histogram illustrating the intraocular pressure for all 1867
district. eyes for which a reading was obtained.

Table 2. Sex and Age Distribution of Subjects Examined* Table 3. Age-Specific Prevalence of Gonioscopically
Occludable Angles and Manifest Primary
Age, y Male Female Total Angle-closure Glaucoma (PACG)
40-49 164(40.5) 263(49.0) 427(45.3)
50-59 Occludable Angles, % Manifest PACG, %
120(29.6) 156(29.0) 276(29.3)
60-69 81(20.0) 82(15.3) 163(17.3) Female Famale
70-79 32(7.9) 30(5.6) 62(6.6) Male (95% (95% Male (95% (95%
80-89 8(2.0) 6(1.1) 14(1.5) Confidence Confidence Confidence Confidence
Total 405 (100) 537 (100) 942 (100) Age, y Interval) Interval) Interval) Interval)
40-49 0.0 5.0 (3-8) 0.0 0.8(0-1.9)
* Values are expressed as number (percentage) of subjects. 50-59 3.0 (0-5) 12.0(7-17) 0.8 (0-2.4) 1.3(0-3.1)
60-69 6.0(1-12) 15.0(7-23) 2.5 (0-5.9) 4.9 (0.2-9.6)
=:70 17.0(6-29) 14.0 (3-26) 7.5(0-15.7) 0.0
bidity it causes. By using rigorous examination and di¬ 40-87 4.2 (2-7) 8.7(6-11) 1.5(0.3-2.7) 1.5(0.5-2.5)
agnostic techniques in all subjects examined, we hoped
to clarify the seemingly contradictory data about glau¬
coma prevalence in east Asia. Because of its role at the

presumed center of human evolution in the region, Mon¬
golia was considered an ideal location for this type of
study.
RESULTS
From a total of 1000 subjects selected, we examined 942
(94.2%) during a 13-week period between May 25,1995,
and August 25, 1995. A 100% response was obtained in
all areas except Renchinlhumbe, Mongolia. The median
age of the men was 52 years (range, 40-83 years) and of
the women was 50 years (range, 40-87 years). The age
and sex distribution data of those examined are given in
Table 2. The mean (±SD) IOP was 12.7±3.4 mm Hg
(95% confidence interval [CI], 12.6-12.9) for the men
and 12.5±2.9mmHg (95% CI, 12.3-12.7) for the women.
These subjects included 17 men and 47 women. The pro¬
portion of women with occludable angles was greater than
men in subjects in their 40s (P=.004), 50s (P= .005), and 60s
(P= .08). The prevalence of occludable angles and manifest
glaucoma for men and women is given for each decade in
Table 3. Of the 64 subjects with gonioscopically occlud¬
able angles, 43 had a steep iris profile, 16 had a regular iris
profile, and 5 had an angulated (plateau) iris profile.
The prevalence of PACG in men was 1.5% (6 sub¬
jects), and, in women, it was 1.5% (8 subjects). The popu¬
lation prevalence of 1.4% in the 40 years and older group
had a 95% CI of 0.11% to 2.22%. Chronic angle closure
was diagnosed in 12 individuals, 11 of whom had glau¬
comatous visual field loss. Intermittent angle closure was
diagnosed in one subject whose fellow eye was blind as
a result of corneal scarring. Two cases of previous acute

Graphical representation shows the characteristic ap¬
proximation to a Gaussian distribution with a slight skew
in favor of higher pressures (Figure). If subjects with
manifest or suspected glaucoma were excluded, these
mean values became 12.4±2.8 mm Hg for each sex. The
median IOP for the whole sample was 12 mm Hg; 7% of
the population had an IOP that was less than 9 mm Hg,
and 6% had an IOP that was greater than 17 mm Hg.
Gonioscopy identified an occludable angle in at least
one eye of 64 subjects (prevalence, 6.4%; 95% CI, 4.3-8.5).
angle closure were detected (one in which chronic angle
closure occurred in the fellow eye); both affected eyes
were blind. Of the 14 subjects with PACG, all of whom
were asymptomatic on examination, only 3 had a his¬
tory of intermittent visual blurring, ocular pain, and the
presence of halos. Latent angle closure was diagnosed in
an additional 19 subjects (3 men and 16 women). La¬
tent angle closure was diagnosed on the basis of the pres¬
ence of peripheral anterior synechiae in 10 subjects, a posi¬
tive result on the provocation test in 7 subjects, and

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 Table 4. Patients With Manifest Glaucoma4

IOP COR Field! Diagnosis

Patient No./
Age, y/Sex OD OS OD OS OD OS OD OS Blindness, Cause
Angle-closure Glaucoma
1/67/F 16 18 0.4 0.3 Probable Normal Chronic Latent
2/56/F 18 27 0.4 0.5 Normal Normal Latent Chronic
3/60/F 6 26 0.3 0.3 Normal Probable Latent Chronic
4/69/F 18 34 0.5 0.9 Normal Unreliable Latent Chronic Blind (OS), glaucoma
5/69/F 16 16 0.9 1.0 Unreliable Unreliable Chronic Chronic Blind, glaucoma
6/49/F 12 12 0.3 0.9 Normal Unreliable Latent Chronic Blind (OS), glaucoma
7/59/F 20 31 0.3 0.9 Normal Unreliable Chronic Chronic Blind (OS), glaucoma
8/49/F 14 12 1.0 0.4 Unreliable Normal Chronic Latent Blind (OD), glaucoma
9/69/M 15 0.3 Normal Unreliable Aphakic Acute Blind (OS), glaucoma
10/52/M 23 12 0.5 0.5 Normal Normal Chronic Latent
11/78/M 22 19 Unreliable Unreliable Chronic Latent Blind, cataracts
12/77/M 17 24 0.9 0.8 Definite Definite Chronic Mixed mechanism Blind, glaucoma
13/66/M 9 0.2 Normal Unreliable Intermittent Nonglaucomatous Blind (OS), keratitis
14/77/M 16 28 Unreliable Unreliable Acute Chronic(PXF) Blind, glaucoma
Open-angle Glaucoma
15/80/F 13 13 0.8 0.6 Definite Probable Primary Primary
16/64/M 8 10 08 0.6 Probable Probable Primary Primary
17/68/M 20 12 0.7 0.4 Definite Normal Primary Suspect
18/79/M 24 20 0.8 0.5 Definite Unreliable Primary OHT+BRVO Blind, glaucoma and BRVO
19/68/M 14 13 0.4 0.4 Normal Probable Normal Primary
20/51/F 14 25 0.2 0.3 Normal Probable Normal Secondary (uveitic)
21/58/M 40 16 0.9 0.5 Unreliable Unreliable Secondary (PXF) Normal
22/65/M 30 18 0.9 0.7 Definite Probable Secondary (PXF) Secondary (PXF) Blind (OD), glaucoma
*BRVO indicates branch retinal vein occlusion; CDR, vertical cup-disc ratio; IOP, Intraocular pressure in millimeters of mercury; OHT, ocular hypertension;
PXF, pseudocapsular exfoliation; and ellipses, data not available.
"[Field indicates characteristics of full threshold visual field analysis; definite, a glaucomatous field with medium to large defects and a shape and size
typical of glaucomatous optic neuropathy; probable, a glaucomatous visual field with slightly smaller and less dense defects atypical of artifact; and unreliable,
the subject was unable to complete the test satisfactorily.
^Indicates disc notch (localized tissue loss at the superior or inferior pole).

excessive pigment on the superior trabecular mesh¬

work in 2 subjects with neither of the preceding factors. Table 5. Subjects With a Visual Acuity
of Less Than 20/400 (3/60) in the Better Eye
Thirty-one individuals were classified as angle-closure or Severely Constricted Visual Fields*
suspects (23 women and 8 men). No cases of secondary
angle closure were detected. Causet Male Female Total
Primary open-angle glaucoma was diagnosed in 5 3 (0.7) 1 4
Glaucoma (0.2) (0.4)
subjects (prevalence, 0.50%; 95% CI, 0.11-0.89), 4 of
whom were men. Of these 5 subjects, only 2 had an IOP Degenerative myopia 0 (0.0) 2 (0.4) 2 (0.2)
Cataract or aphakia 1 (0.2) 1 (0.2) 2 (0.2)
that was greater than 19 mm Hg. Secondary open-angle Retinal (ARMD) 1(0.2) 0(0.0) 1(0.1)
glaucoma was diagnosed in 3 subjects (prevalence, 0.30%; Corneal (CDK) 1(0.2) 0(0.0) 1(0.1)
95% CI, 0.05-0.55). One of these subjects had chronic Other 0(0.0) 2(0.4) 2(0.2)
anterior uveitis, and the other 2 had pseudocapsular ex¬ Total 6(1.5) 6(1.1) 12(1.2)
foliation. One subject with chronic angle-closure glau¬
coma also had pseudocapsular exfoliation. Bilateral pig¬
* Values
are expressed as the number of subjects with the prevalence in

ment dispersion syndrome was detected in one subject

with ocular hypertension.
A total of 22 cases of manifest glaucoma were de¬
tected in this survey, of which 20 (91%) were newly di¬
agnosed. Of the 2 subjects in whom manifest glaucoma
was previously diagnosed, the first had chronic angle-
closure glaucoma and had undergone surgical periph¬
eral iridectomy, and the second had a previous attack of
acute angle-closure glaucoma, the fellow eye being apha¬
kic with a large peripheral iridectomy. The physical signs
found in patients with manifest glaucoma are summa¬
rized in Table 4.
Twelve subjects were bilaterally blind, giving a popu¬
lation prevalence of 1.2% (95% CI, 0.36-2.04) in the sub-
subjects 40 years of age or older given in parentheses.
tARMD denotes bilateral large macular disciform scars in an
81-year-old patient; CDK, climatic droplet keratopathy.
jects 40 years and older. Glaucoma was the main cause
of blindness, affecting 4 subjects (prevalence, 0.42%; 95%
CI, 0.01-0.83). Cataracts and degenerative myopia each
caused another 2 cases of blindness. One individual was
blinded by age-related macular degeneration. Climatic
droplet keratopathy was responsible for the blindness of
another subject. These data are summarized in Table 5.
Thirty-four subjects were blind in 1 eye, trauma being
the major cause (8 subjects). Seven people were blind in
1 eye from glaucoma. Six subjects were blind in 1 eye
from uncorrected, degenerative high myopia. Corneal

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 Table 6. Comparison of the Published Prevalence of Primary Glaucomas
in the 40 Years and Older Age Group of Different Populations*
United States19
Type of Glaucoma Japan5 W China4
PACG 0.34 0.40}: 0.90}:
POAG 2.62 1.44 4.97
No. of subjects a40 y 8126 2913 2395
*PACG indicates primary angle-closure glaucoma; POAG, primary open-angle
age standardized.
"[Data obtained from this study.
\Data obtained from J. M. Tielsch, PhD, oral communication, April 24, 1996.
^Calculated from data published in reference 8.
scars or climatic droplet keratopathy caused unilateral
blindness in another 6 subjects. One subject listed as uni¬
laterally blind from glaucoma had been enucleated as a
child, following a diagnosis of buphthalmos.
A study of the interobserver agreement (between
P.J.F and P.H.A.) for Shaffer gonioscopic grading gave a
weighted of 0.65, indicating good agreement. A com¬
parison of the IOP measurements between these 2 ob¬
servers found a mean difference of 1.1 mm Hg. The 95%
limits of agreement for these readings were —2.2 to 4.5
mm Hg (mean difference± 1.96 SDs of difference).18
COMMENT
To our knowledge, this is the first population-based glau¬
coma survey undertaken in east Asia in which all subjects
have been assessed not only by tonometry and slit-lamp ex¬
amination (including disc assessment) but also by visual field
testing and gonioscopy. The response rates are exception¬
ally high for any population-based survey, especially con¬
sidering that many participants traveled for several hours
on horseback or motorcycle to reach the towns where they
were examined. Our study sample included 57% women and
43% men. According to census data, the population of Hövs¬
göl aged 40 years and older is 54.6% women and 45.4% men.
The male-female ratio of the sample was equivalent to this
in all locations, except in Renchinlhumbe sum (female-male
ratio, 62%:38%). As this was the only area where a 100% re¬
sponse was not obtained, nonattendance of working men
must be invoked as an explanation for the greater excess of
women. The female population aged 70 years and older in
the Hövsgöl region outnumbers the males by a factor of 2:1.
This pattern was not reflected in our sample, which was by
chance, therefore, not wholly representative in this respect.
During the course of this study, we noticed little difference
in lifestyle between urban and rural communities. Our soft¬
ware for the calculation of confidence intervals did not take
into account the use of systematic sampling in rural areas.
This would have introduced some approximation into the
calculated figures.
Population-based surveys in the 40 years and older
group in different countries show a spectrum in the preva¬
lence of PACG; whites are at one extreme, and Inuit (ie,
Eskimos) are at the other. The Baltimore Eye Survey found
a PACG prevalence of 0.4% among whites in the United
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Population 40 y, %
Alaskan
Mongolia! Eskimos8 Greenland10
1.40 1.40 2.60 5.00
0.03 0.50 0.26 1.30
3147 942 377§ 396
glaucoma. The reference source of the data is indicated. These values are not
States 0- M. Tielsch, PhD, oral communication, April 24,
1996). Among Inuit, this percentage rises from 2.6% in
Alaska8 to 2.9% in Canada9 and to 5.0% in Greenland.10
Falling between these percentages are the Chinese who
have a prevalence of 1.4% in Beijing4 and the Mongols
who have a prevalence of manifest PACG of 1.4%. In each
study, however, the diagnostic criteria were slightly dif¬
ferent. When criteria identical to those used in China are
applied to our sample, a prevalence of 1.6% is obtained
(a combination of some manifest and some latent PACG
subjects). This agreement strengthens the inferences that
may be drawn, despite the width of confidence intervals
for our data. In addition to an interracial variation in preva¬
lence, the natural history of PACG differs between whites
and Mongols, favoring a chronic, asymptomatic course
in the latter. Only 2 eyes of 14 subjects with manifest
PACG had signs of acute angle closure in this study. The
mean age of the subjects with manifest PACG was 64
years. The prevalence in subjects aged 60 years and older
was 3.8% (95% CI, 1.4-6.2), highlighting the fact that
PACG is an age-related phenomenon.
Available data suggest that a racial spectrum in the
prevalence of POAG also exists. It is believed that the con¬
dition is rare in the Inuit and the Chinese and more com¬
mon among whites.2 The Baltimore Eye Survey found a
crude prevalence of 1.4% in whites.19 The finding of a preva¬
lence of 0.50% in Mongolians is substantially lower, as an¬
ticipated. Although the sample population in both studies
was aged 40 years and older, all subjects with POAG de¬
tected were older than 50 years in the current study, and
all but 1 of 42 subjects in the Baltimore Eye Survey were a
similar age. In Beijing, 11 cases of POAG were detected.
All subjects except 1 were younger than 40 years, giving a
remarkably low prevalence of 0.03% in the 40 years and
older group.4 In contrast, 2.6% of the Japanese aged 40 years
and older had (normotensive and hypertensive) POAG, ac¬
cording to the results of a nationwide survey.5 These re¬
sults are intriguing because the Japanese are genetically
much closer to the Mongolians and the Chinese, although
the POAG prevalence is at least the equal of that found in
white nations. An increase in the prevalence of POAG with
age is demonstrated in white and black Americans,19 Car-
ibbeans,20 and Japanese.5 Mongolia has a smaller propor¬
tion of its population surviving to the advanced ages seen
in industrialized nations such as the United States and Ja-
 pan.Therefore, adjustment for age is necessary to draw
meaningful comparisons. If the white population exam¬
ined in the Baltimore Eye Survey had a similar age struc¬
ture to our study population, the crude prevalence of POAG
in the older than 40 years age group would be 0.69%, not
1.44% (direct age standardization to Hövsgöl Survey popu¬
lation) Thus, it seems that Mongols may be at similar risk
of POAG as whites if they attain a sufficient age, although
. Accepted for publication May 31, 1996.
the width of the confidence intervals highlights that this
inference is drawn from 5 cases only.
The Chinese and the Japanese have a lower mean IOP
than whites.4,5 The mean IOP of the Mongols is even lower
than that found in the 2 neighboring populations (ie, China
and Japan), although the figures for the Japanese are de¬
rived from noncontact tonometry and are, therefore, not
strictly comparable. Despite the use of a race-specific value
for the upper limit of the normal IOP measurement de¬
rived from the Inuit and the Chinese, the chosen value of
19 mm Hg was too high. Our normative data from Mon¬
golia suggest that 17 mm Hg (mean + 2 SDs) would have
been more accurate. Despite a revised definition, only 2 of
the 5 POAG cases had an IOP greater than 19 mm Hg. This
value is in agreement with the findings in Japan, where,
although a race-specific value for pressure was not used,
normotensive POAG was diagnosed at a frequency of 3.7:1
vs hypertensive POAG.5 Race-specific glaucoma preva¬
lence data are summarized in Table 6.
A previous population-based study of more than 4300
Mongols found that cataract and glaucoma accounted for
equal proportions of blindness (36% and 35%, respec¬
tively) .14 The findings of this study were that glaucoma ac¬
counted for a similar proportion (33%) of blindness but
that cataract blindness was less prevalent. These data dif¬
fer from the World Health Organization's figures on blind¬
ness in China and other Asian countries, where cataract is
listed as the leading cause of blindness. Glaucoma is the
second-leading cause of blindness in China (22.7% of the
total) but third behind trachoma for other Asian coun¬
tries (16.7%).' We have found no trachoma in Mongolia
during this or previous studies.14
We examined and treated 47 of the region's regis¬
tered patients with glaucoma. Thirty-four of these pa¬
tients were blind in at least one eye, 26 as a consequence
of PACG. Owing to the lack of surgical facilities and the
irregular supply of medication, 15 patients were not pro¬
tected by peripheral iridectomy or pilocarpine. Among our
survey sample, glaucoma was the leading cause of blind¬
ness. Twenty (91%) of the 22 manifest glaucoma cases were
previously undiagnosed. Also identified were 75 cases of
ocular hypertension or latent or suspected glaucoma. A
portable YAG laser was used to perform peripheral iri-
dotomy in subjects with manifest, latent, and suspect PACG
who we believed would benefit from this procedure. Among
the 942 subjects aged 40 years and older who were sur¬
veyed, 9.7% received glaucoma treatment or were re¬
ferred for continuing medical assessment to detect pro¬
gression to glaucoma, suggesting that 40 000 people in
Mongolia may be in need of similar management. The like¬
lihood that Mongolian and neighboring populations share
a common genetic heritage suggests that glaucoma may
be a major cause of ocular morbidity throughout the re¬
gion of east Asia. This issue should be investigated fur-
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ther. This is particularly important as continental east Asia
undergoes economic growth. The age structure of the re¬
gion is changing to more closely resemble that of major
industrial nations like Japan. Glaucoma prevalence may,
therefore, increase as a consequence.1
This study was funded by the British Council for Pre¬
vention of Blindness, London, with additional support from
Danida, Copenhagen, Denmark, the International Glau¬
coma Association, London, and the Danish Association for
the Blind, Copenhagen. The Henson CFA 3000 Field Ana¬
lyzer used in this study was donated by Tinsley Medical
Instruments, Croyden.
We thank Lodoisambuugiin Damdinsuren, MD, and
the medical staff of Hövsgöl aimag, Pak Sang Lee, MSc,
and Darwin C. Minnassian, FRCS, of the Institute of Oph¬
thalmology, London, and AlanJ. K. Sanders, Reading, En¬
gland, all of whom provided invaluable help in ensuring
the success of this project. We are grateful to John F. Salmon,
MD, FRCS, Roger Hitchings, FRCS, and Peng T. Khaw,
PhD, FRCS, for advice on the study design.
Reprints: Gordon J. Johnson, MD, FRCSC, Interna¬
tional Centre for Eye Health, Institute of Ophthalmology,
Bath St, London EC1V 9EL, England.
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