Sociodemographic and Clinical Characteristics of Participants Attended Glaucoma Screening Week in Benghazi 2023 ()
1. Introduction
Early diagnosis of glaucoma is critical to mitigating irreversible vision loss, as the disease progresses asymptomatically until advanced stages. Timely detection enables interventions that preserve visual function and reduce long-term healthcare burdens through cost-effective management. However, sociodemographic disparities—including age, ethnicity, socioeconomic status, and geographic healthcare access—disproportionately delay diagnosis and treatment. Older adults, racially marginalized groups, and underserved populations face heightened risks due to barriers such as limited screening availability, health literacy gaps, and systemic inequities in care. Addressing these disparities is essential to improving outcomes, as delayed diagnosis exacerbates preventable blindness and widens health inequities. A dual focus on advancing early diagnostic tools and dismantling sociodemographic barriers underscores the intersection of clinical and public health strategies in combating glaucoma’s global burden.
It has been estimated that the second most prevalent cause of blindness worldwide is glaucoma and the most prevalent cause of irreversible blindness [1] [2].
Glaucoma is a progressive chronic optic neuropathy in which intraocular pressure (IOP) and other currently known factors such as heredity, age, and gender among others contribute to the damage characterized by acquired atrophy of the optic nerve and loss of retinal ganglion cells [3].
The effective management of glaucoma depends on early presentation and diagnosis to prevent blindness [4]. The absence of pain conceals the need for regular eye examinations especially in developing countries where access to health care facilities is costly. Also, the glaucoma presentation pattern in developing countries is greatly influenced by underequipped eye care facilities, poor distribution of eye care resources, the inadequacy of skilled personnel for the eye industry, poor education and awareness, and poverty. This pattern of presentation is different from that of the developed world [5].
A large and growing body of evidence shows that socio-demographic factors such as age, race, as well as socioeconomic status (SES), such as income and education, can influence health outcomes [6] [7].
Studies have shown that increasing age is the most important predictor of blindness. However, the female sex, low educational attainment as well as low SES have also been shown to be associated with blindness [8] [9].
Rim et al. found that there was a substantial socio-demographic disparity in eye care utilisation in Korea, and that men with low financial income and education level were especially at risk [10].
Glaucoma is a group of diseases that cause structural damage and visual field dysfunction, leading to progressive and irreversible vision loss [11]. It is the second leading cause of blindness globally, accounting for 8% of blindness. It is also the leading cause of irreversible blindness globally [12].
It has been reported that the lack of awareness of the disease leads to a late presentation at service delivery points [13].
World Glaucoma Week is a global joint initiative between the World Glaucoma Association (WGA) and the World Glaucoma Patient Network (WGPN), in order to raise awareness on glaucoma.
This study is aimed at finding the socio-demographic characteristics and ocular status of participants at a screening programme during the World Glaucoma Week celebration in Benghazi Teaching Eye Hospital-Libya in 2023 and, data so obtained will help form the framework for policymakers on community-based intervention programs that could be incorporated into the primary eye health care.
2. Patients and Methods
2.1. Study Design
This was a hospital-based cross-sectional descriptive study of participants who attended Glaucoma screening week in Benghazi in 2023. It sought to describe the socio-demographic characteristics and clinical profile of patients attended throughout that week.
2.2. Study Setting
This study was carried out at the premises of the out-patient ophthalmology clinic affiliated with Benghazi Teaching Eye Hospital in Benghazi-Libya in the screening week for glaucoma in 2023.
This facility is a public tertiary eye care facility with the full complement of eye care staff and unlike the public facilities that have the necessary logistics and equipment for comprehensive glaucoma care, and it is one of the most utilized facilities in Benghazi.
2.3. The Sample Size and Sampling Method
Screened 367 participants during the Glaucoma screening week in Benghazi 2023. It was a simple random sampling.
2.4. Inclusion and Exclusion Criteria
The Study included all attendees to glaucoma week in Benghazi 2023, and there was no exclusion for the participants.
2.5. Ethical Considerations
The study and data collection conformed to all local laws and were compliant with the principles of the Declaration of Helsinki.
2.6. Methods
Data collection involved the use of a data extraction sheet as shown as Appendix to collect data on the first visits of the participants on sociodemographics that included gender, age, occupation, source of information about glaucoma week, and full medical and ophthalmological history, family history of glaucoma. Then all participants had an ophthalmological examination that included:
Visual acuities using Snellens chart, refraction using TOPCON KR-800 Autorefractometer (Topcon, Tokyo, Japan), ophthalmological examination using slit lamp, intraocular pressure by Goldmann applanation tonometer, fundus examination by use of +90.00 D biomicroscopic fundoscopy and cup to disc ratio using ZEISS Cirrus HD-Optical Coherence Tomography (OCT).
2.7. Data Analysis
Data were analyzed using the International Business Machines Corporation’s Statistical Package for the Social Sciences, (IBM SPSS) version 25 (SPSS Inc, Chicago, USA). A descriptive analysis was carried out, which involved calculating descriptive data such as mean, median, and percentage.
3. Results
This study screened 367 participants for ophthalmological disorders including glaucoma. The mean age of the sample was 57.8 years, with a standard deviation of 12.2, and median age is 59 years, minimum age of 4 and a maximum of 88 years, 23 persons (6.3%) are younger than 40 years compared to 343 persons (93.7) are forty years and more (Table 1, Figure 1).
Table 1. Age statistics of the sample.
Age in years |
N |
363 |
Missing |
4 |
Mean |
57.8 |
Median |
59 |
Standard deviation |
12.2 |
Minimum |
4 |
Maximum |
88 |
Age < 40 |
23 (6.3%) |
Age ≥ 40 |
343 (93.7%) |
Figure 1. Age distribution of the sample.
Male gender is greater among the sample, with 218 males (59.4%) and 149 females (40.6%). Libyan nationality is the predominant representing 92.9% of the sample and white race represented 93.7% (Table 2).
Table 2. Sociodemographic characteristics of the sample.
Characteristics |
Frequency |
Percent |
Gender |
Male |
218 |
59.4 |
Female |
149 |
40.6 |
Nationality |
Libyan |
341 |
92.9 |
Non-Libyan |
15 |
4.1 |
missing |
11 |
3 |
Race |
White |
344 |
93.7 |
Black |
23 |
6.3 |
Table 3 shows distribution of the study sample according to their socio-economic profiles as the following.
Occupation has 367 observations and 6 levels. Public worker n =106, 37.46%. Other job: n = 81, 28.62%. Unemployed: n = 76, 26.86%. Technician: n = 11, 3.89%. Professinal: n = 5, 1.77%. Student: n = 4, 1.41%. There are 84 missing values.
Education level has 367 observations and 4 levels. University: n = 96, 35.8%. Secondary education: n = 79, 29.5%. Primary education: n = 63, 23.5%. No Formal education: n = 30, 11.2%. There are 99 missing values.
Socio-economic level (SES) has 367 observations and 5 levels. Middle: n = 145, 39.5%. High: n = 75, 20.4%. Low: n = 72, 19.6%. Unemployed: n = 51, 13.9%. Very low: n = 11, 3.0%. There are 13 missing values.
Table 3. Sociodemographic characteristics of the sample.
Characteristics |
Frequency |
Percent |
Occupation |
public servant |
131 |
35.7 |
Student |
5 |
1.4 |
Unemployed |
98 |
26.7 |
Technician |
16 |
4.4 |
Others |
99 |
27.0 |
Professional |
9 |
2.5 |
Missing |
84 |
22.8 |
Education level |
No formal education |
38 |
10.4 |
Primary education |
76 |
20.7 |
Secondary education |
103 |
28.1 |
University education |
122 |
33.2 |
Missing |
99 |
26.9 |
Socioeconomic status |
Upper |
75 |
20.4 |
Middle |
145 |
39.5 |
Low |
72 |
19.6 |
Very low |
11 |
3.0 |
Unemployed |
51 |
13.9 |
Missing |
13 |
3.5 |
Table 4 shows that 161 (44.1%) of the participants diagnosed with glaucoma while 204(55.9%) do not have glaucoma. Family history of glaucoma is claimed by 127 persons (34.9%), and 237 (64.6%) denied a family history of glaucoma.
Table 4. Frequencies of Glaucoma case and family history of glaucoma.
|
Level |
Count |
% |
Missing |
Glaucoma case |
Yes |
161 |
43.9 |
2 |
No |
204 |
55.6 |
FH of glaucoma |
Yes |
127 |
34.9 |
3 |
No |
237 |
64.6 |
Table 5 shows the presence of chronic morbidity and medical history of the sample as the following.
DM has 367 observations and 2 levels. No: n = 185, 51.4%. Yes: n = 175, 48.6%. There are 7 missing values.
HTN has 367 observations and 2 levels. No: n = 214, 59%. Yes: n = 148, 41%. There are 5 missing values.
Migraine has 367 observations and 2 levels. No: n = 265, 74%. Yes: n = 92, 26%. There are 10 missing values.
Cortisone therapy has 367 observations and 2 levels. No: n = 314, 86%. Yes: n = 50, 14%. There are 3 missing values.
Asthma is reported by 28 persons (7.6%), 315 (85.6%) do not have asthma, 24 missing.
Eczema is reported by 14 persons (3.8%), 337 (91.8%) do not have eczema, 16 missing.
Heart diseases are reported by 49 persons (13.4%), thyroid diseases by 33 persons (9%), and rheumatoid arthritis by 24 participants (6.5%).
Table 5. Medical history of the sample.
Medical problem |
No |
Yes |
Missing |
Count |
% |
Count |
% |
Count |
% |
DM |
185 |
50.4 |
175 |
47.7 |
7 |
1.9 |
HTN |
214 |
53.3 |
148 |
40.3 |
5 |
1.4 |
Migraine |
265 |
72.2 |
92 |
25.1 |
10 |
2.7 |
Corticosteroid therapy |
314 |
85.6 |
50 |
13.6 |
3 |
0.8 |
Asthma |
315 |
85.8 |
28 |
7.6 |
24 |
6.5 |
Eczema |
337 |
91.8 |
14 |
3.8 |
16 |
4.4 |
Heart disease |
309 |
84.2 |
49 |
13.4 |
9 |
2.5 |
Thyroid disease |
322 |
87.7 |
33 |
9.0 |
12 |
3.3 |
Rheumatoid
Arthritis |
313 |
85.3 |
24 |
6.5 |
30 |
8.2 |
Table 6 shows the source of information about glaucoma week, which has 527 observations and 6 levels. Hospital: n = 117, 33.4%. Radio: n = 88, 25.1%. Patient or relative: n = 77, 22.0%. Social media: n = 45, 12.9%. Other source: n = 22, 6.3%. Hospital and radio: n = 1, 0.3%. There are 177 missing values (Figure 2).
Table 6. Source of information about glaucoma week.
Source of information about glaucoma week |
Counts |
% of Total |
Cumulative % |
Hospital |
117 |
33.4 % |
33.4 % |
Radio |
88 |
25.1 % |
58.6 % |
Social media |
45 |
12.9 % |
71.4 % |
Patient or relative |
77 |
22.0 % |
93.4 % |
Other source |
22 |
6.3 % |
99.7 % |
Hospital and radio |
1 |
0.3 % |
100.0 % |
Figure 2. Source of information about glaucoma week.
Table 7 shows the measurements of the vertical cup to disc ratio by OCT, IOP by Goldman applanation tonometer of the sample as the following.
Table 7. Measurements of vertical cup to disc ratio by OCT and Intra ocular pressure (IOP) of the sample by Goldman applanation tonometer.
|
N |
Missing |
Mean |
Median |
SD |
RE vertical cup to disc ratio by OCT |
302 |
65 |
0.45 |
0.30 |
0.23 |
LE vertical cup to disc ratio by OCT |
309 |
58 |
58.62 |
0.40 |
234.26 |
RE IOP by Goldman
applanation tonometer |
298 |
69 |
16.29 |
16.0 |
5.56 |
LE IOP Goldman applanation tonometer |
293 |
74 |
19.95 |
16.0 |
57.67 |
4. Discussion
This study is the first to provide information on the sociodemographic characteristics and clinical profile of persons who attended Glaucoma screening week in Benghazi-Libya. Glaucoma continues to be the commonest cause of avoidable blindness globally despite the renewed strength to create a yearly week-long World Glaucoma awareness campaign. The 2023 World Glaucoma Week celebration was marked in our tertiary clinic with a free eye screening which was well advertised in the media. This ensured that participation was open to a wide range of people of different ages and occupations. The overwhelming representation of participants aged ≥40 years (93.7%) aligns with global evidence identifying age as a critical risk factor for glaucoma, particularly primary open-angle glaucoma (POAG) [14] [15]. However, this raises questions about younger populations in Benghazi. While younger individuals may perceive themselves as low-risk, undetected cases of juvenile glaucoma or secondary glaucoma (e.g., trauma-induced) could be overlooked. In Libya, cultural attitudes toward healthcare—where younger adults may prioritize acute over preventive care—could explain their underrepresentation. Future campaigns could explicitly target younger demographics to dispel misconceptions about glaucoma as an “older adult disease.”
The male predominance (59.4%) contrasts with global epidemiological trends, where females often exhibit higher glaucoma prevalence due to longer life expectancy and hormonal factors. However, this aligns with hospital-based studies in sub-Saharan Africa [15]-[17], suggesting regional patterns in healthcare-seeking behavior. In North Africa, gendered roles may influence access: males, often primary income earners, might prioritize health screenings if they perceive vision loss as a threat to employment. Conversely, women may face barriers such as caregiving responsibilities or limited autonomy to attend screenings. Further qualitative research is needed to explore these dynamics in Benghazi.
The relatively high proportion of university-educated participants (33.2%) mirrors findings from Ghana and India, where education correlates with glaucoma awareness [18] [19]. However, Libya’s literacy rate is 91% (World Bank, 2021), suggesting that even educated populations may lack disease-specific knowledge. This highlights a paradox: while educated individuals are more likely to attend screenings, they may still harbor gaps in understanding glaucoma’s asymptomatic progression. Public health campaigns should combine media messaging with community workshops to bridge this gap, particularly for non-university-educated groups.
The hospital as the primary information source (33.4%) diverges from studies where media dominates [20]. This may reflect the tertiary clinic’s established reputation, drawing existing patients or referrals. Alternatively, media campaigns (despite being “well-advertised”) might have failed to reach broader audiences due to low health literacy or distrust in media sources. In conflict-affected regions like Libya, institutional trust in hospitals may outweigh trust in media, which is often politicized. To enhance reach, future campaigns could collaborate with community leaders or religious institutions, which serve as trusted information hubs in many Arab societies.
The high glaucoma diagnosis rate (44.1%) underscores the value of targeted screenings during awareness weeks. Comparatively, population-based studies report lower prevalence (3% - 5% in adults >40 years), suggesting this cohort may have self-selected due to symptoms or risk factors. However, if Benghazi’s prevalence is genuinely elevated, environmental factors (e.g., solar exposure, smoking) or genetic susceptibility unique to North African populations warrant investigation.
The lower familial history (34.9% vs. 60% in Tasmania [21] may reflect underreporting due to fragmented family structures, stigma around blindness, or poor intergenerational health communication in Libyan society. Alternatively, it could signal a stronger role for non-genetic risk factors (e.g., untreated ocular hypertension, diabetes) in this population. Genetic studies in Libyan cohorts are needed to clarify hereditary contributions to POAG.
The applanation tonometer was the instrument used at the tertiary eye center to measure intraocular pressure (IOP) since it is the gold standard for IOP measurement [22]. The mean IOP (16.29 - 19.95 mmHg) aligns with normal ranges but starkly contrasts with African studies reporting means >30 mmHg [14] [16]. This discrepancy likely stems from differing cohorts: cited studies focused on glaucoma patients, whereas 55.9% of our cohort were healthy. However, even among glaucoma patients in our study, IOPs may be lower due to early detection or effective pre-screening management (e.g., hypotensive medications). This reinforces the limitations of relying solely on IOP for diagnosis, particularly in normal-tension glaucoma, which is prevalent in certain ethnic groups. The cup-to-disc ratio is a prominent sign of glaucoma among patients. With the advancement in technology for the examination of the retina and optic nerve head, sophisticated techniques such as optical coherence tomography (OCT) provide quantitative measurements of vertical cup to disc ratio and other measurements [23]-[25]. In our study the median vertical CDR (0.3 - 0.4) diverges sharply from Samuel Kyei’s study (0.9) [26], likely reflecting differences in participant profiles. Kyei’s cohort included advanced glaucoma patients, whereas our screening captured early-stage or pre-perimetric cases. Ethnic variations in optic disc morphology may also play a role: African populations typically have larger CDRs than Europeans or Arabs, independent of disease. The use of OCT in our study—a tool absent in many resource-limited African settings—enabled precise detection of subtle structural changes, advocating for its integration into screenings to identify glaucoma before irreversible vision loss.
5. Conclusion
This study, the first to profile attendees of a glaucoma screening initiative in Benghazi, Libya, reveals critical insights into the sociodemographic and clinical dimensions of glaucoma in a region where such data have historically been scarce. The findings challenge conventional assumptions, underscore the interplay of cultural and biological factors, and highlight actionable pathways for improving glaucoma care in North Africa.
5.1. Sociodemographic Patterns: A Reflection of Access, Not Risk
The predominance of males (59.4%) and individuals over 40 (93.7%) underscores a healthcare engagement gap rather than a true epidemiological distribution. While age is a well-established risk factor for glaucoma, the near-exclusion of younger participants likely reflects systemic barriers: cultural perceptions of glaucoma as an “aging disease,” limited preventive health literacy, and gender roles that prioritize male access to healthcare. The overrepresentation of university-educated participants (33.2%) further signals inequities in health outreach. Educated individuals, often more health-literate and economically empowered, are more likely to attend screenings, leaving marginalized groups (e.g., rural populations, less-educated women) underserved. This disparity calls for decentralized, community-driven screening programs that bridge gaps in access and education.
5.2. High Glaucoma Prevalence (44.1%): A Dual Narrative
The striking proportion of glaucoma diagnoses—far exceeding global averages—carries two potential explanations:
Effective Case-Finding: The screening’s use of gold-standard tools (applanation tonometry, OCT) and its timing during Glaucoma Week likely attracted high-risk individuals (e.g., those with undiagnosed symptoms or familial history), demonstrating the value of targeted awareness campaigns.
A Silent Epidemic: If this rate reflects true regional prevalence, it signals a public health crisis. Because this may have allowed glaucoma to proliferate untreated, environmental factors, such as high UV exposure in arid climates or untreated diabetes, could compound the risk.
5.3. Normal IOP and CDR: Rethinking Diagnostic Paradigms
The majority of participants, including those diagnosed with glaucoma, exhibited normal IOP (16.29 - 19.95 mmHg) and vertical cup-to-disc ratios (CDR 0.3 - 0.4). This challenges the traditional reliance on IOP as a diagnostic cornerstone and emphasizes:
The Prevalence of Normal-Tension Glaucoma (NTG): NTG, common in Asian and Arab populations, may dominate Benghazi’s glaucoma profile. This subtype, invisible to IOP-centric screenings, demands structural assessments (e.g., OCT) to detect optic nerve damage before irreversible vision loss.
Ethnic Variations in Optic Disc Morphology: The lower CDR values compared to African studies (e.g., CDR 0.9 in Ghana [26]) highlight the need for population-specific reference ranges. Arab populations may have smaller optic discs, making universal CDR thresholds (e.g., >0.6) potentially misleading.
5.4. Familial History (34.9%): A Cultural or Biological Signal
The lower familial history compared to Tasmanian studies (60% [21]) may reflect underreporting due to stigma around blindness, or a true predominance of sporadic glaucoma cases. This finding urges caution: while genetics are key in POAG, environmental and systemic health factors (e.g., vascular disease, steroid misuse) may be more salient in Libya’s context.
5.5. Clinical and Policy Implications
Beyond IOP: A Structural Revolution: The study advocates for OCT as a frontline tool in glaucoma screenings, particularly in resource-limited settings where NTG may be prevalent but underdiagnosed.
Gender-Equitable Outreach: To address male predominance, screenings could partner with female community leaders or offer mobile clinics in residential areas to reduce access barriers for women.
Education Tailored to Reality: Simplify glaucoma messaging for non-university-educated groups using visual aids (e.g., infographics in Arabic) and leverage mosques or local media (e.g., radio) to broaden reach.
6. Limitations and Future Directions
As a hospital-based study, the findings may not generalize to Libya’s broader population. Community-based screenings are critical to capture undiagnosed cases, particularly in rural areas. Longitudinal follow-up could clarify progression rates, while genetic studies might unravel the role of hereditary vs. environmental risk factors. Establishing Arab-specific CDR and IOP norms will refine diagnostic accuracy and reduce over-/underdiagnosis.
Conflicts of Interest
The authors declare no conflicts of interest.
Appendix
Glaucoma work sheet
Date: \ \20 ID:
Name:
Age:……
Age: above 40? yes ……..no ……..
Gender:…………………. Race…………….
Phone number ………………………Nationality:……………
Occupation:
civil /public servant |
|
Technician |
|
Student |
|
Others |
|
Unemployed |
|
|
|
Professional |
|
|
|
Education:
no formal education |
|
Secondary education |
|
Primary education |
|
Post secondary education |
|
Any Complaint:
ocular pain …………, headache………,pain around the eye………….,redness……..,haloes around the light …………
Blurring of vision…….,itching/irritation …..,
tearing………, floaters……,flashes of light ……….others ……….
Past medical history : Diabetes mellitus: yes □ No □
Hypertension : yes no ,
ischemic heart disease: yes □ no □
Migraine: yes □ no □
Thyroid eye disease : yes □ No □
Bronchial asthma : yes □ No □
Eczema: yes □ No □
Presence of vascular disease : yes …….. no ……….
H/O any other chronic disease ……………………………
Past ocular surgery: yes □ No □
If yes what is the ocular surgery done ………………
H/O glaucoma surgery …………….
Past surgical history:
Any history of trauma: blunt…….. or penetrating………….
Family history of glaucoma: yes □ no □,
If yes who has a glaucoma in the family:
first degree relative……., second degree relative ……….3rd degree relative ……..
duration of glaucoma:
less than one year………….,1 - 5 years …………, more than 5 years ……….or
don’t know…………
Age of the patient at presentation of the disease ………….
F/H of any other ocular disease:
F\H of any chronic medical disease:
Drug history: glaucoma cases :
Number of antiglaucoma eye drops used: none ………, one ………, two ……., three, …….four ………..
Name of antiglaucoma used …………..
Dose …………………………………………, side effects ……………
Any other medication used …………………..
In glaucoma patients: Where was the diagnosis done: in the hospital ………………, out of the hospital …………… or could not tell…………………………
Source of informations about glaucoma week : from the hospital ……………..,
TV\radio …………………… , relatives of the patient ………………., other sources ……….
Social history: history of smoking: yes □ or no □
Socioeconomic status: upper (salary ≥15oo LD) ……….,middle (salary <1500-900 LD) …….. low (salary 900 LD) ………very low (< 900 up to 450LD) ……..unemployed ……………
Very far (out of Benghazi ) ……….
Examination:
|
RE |
LE |
Visual acuity(non aided) |
|
|
Autorefractometery (ARM) |
|
|
Lid |
|
|
conjunctiva |
|
|
Cornea |
|
|
sclera |
|
|
Anterior chamber |
|
|
iris |
|
|
pupil |
|
|
lens |
|
|
IOP by Goldmann Applanation tonometry |
|
|
|
|
|
Fundus : Vitreous : Optic disc : Macula : Vessels : |
|
|
Gonioscopy:
RE …………………………………………………………………………
LE:………………………………………………………………………….
Comment: Type of glaucoma: RE : open angle ………….. or closed angle …………
LE: open angle glaucoma ………… or closed angle glaucoma………..
Primary or secondary glaucoma :
RE ……………
LE …………….
Investigations:
OCT optic nerve:
RE …………………………………….
LE……………………………………….
Or unlikely…………………………..