An eye specialist, or ophthalmologist, is a doctor who diagnoses and treats various eye disorders and is qualified to perform eye surgeries. An ophthalmologist differs from an optometrist, who performs vision tests and prescribes corrective lenses and eyewear. 

In Singapore, several prevalent eye issues require individuals to consult with ophthalmologists. These include myopia, or nearsightedness, common among children and young adults [1], and cataract, usually associated with older adults [2]. It is important to consult with an ophthalmologist for eye issues and problems such as these, as they can worsen over time and even lead to permanent vision loss. 

With Singapore’s ageing population, maintaining eye health is critical as age-related conditions, such as cataract, glaucoma and macular degeneration, become more common. Keep reading to find out what eye specialists do, when to visit an ophthalmologist, and how to choose the right one in Singapore.

Specialised Services by Eye Specialists 

Eye specialists in Singapore offer an array of advanced services to address the unique needs of patients. These professionals are equipped to provide medical care beyond routine checkups, ensuring precise diagnoses and tailored treatments. 

From managing eye diseases to prescribing medications and performing corrective surgeries, the services typically aim to improve visual function. Catering to all age groups, eye specialists offer specialised pediatric care to help children manage vision issues early. Through their experience, they ensure patients receive comprehensive and personalised attention to manage long-term eye health and improve quality of life.

Here are some services carried out by eye specialists: 

Comprehensive Eye Examinations

Eye specialists carry out detailed evaluations to detect conditions like cataract, glaucoma, macular degeneration, and diabetic retinopathy. Comprehensive eye exams and screenings not only preserve vision but also provide insights into a person’s overall health, as systemic conditions like hypertension or diabetes can manifest in the eyes. These include:

• Visual Acuity Test: Measures how clearly you can see at different distances using an eye chart.
• Refraction Test: Determines the presence of refractive errors, such as myopia, hyperopia, astigmatism, or presbyopia, to prescribe corrective lenses if needed.
• Pupil Reaction and Eye Muscle Tests: Evaluates how the pupils respond to light and assesses eye movement.
• Visual Field Test: Identifies any loss of peripheral (side) vision, which can signal conditions like glaucoma or neurological problems.
• Slit Lamp Examination: Involves a microscope with a bright light to examine the structures of the eye, including the cornea, iris, lens, eye nerve and retina.
• Intraocular Pressure Test (Tonometry): Measures the pressure inside your eyes to screen for glaucoma.
• Dilated Eye Exam: Eye drops are used to dilate your pupils so that the specialist can thoroughly examine the retina and eye nerve for signs of damage or disease.
• Specialised tests: Advanced imaging techniques such as Optical Coherence Tomography (OCT) or retinal photography may be performed to get detailed images of the eye's structures.

Surgical Treatments

Eye specialists in Singapore use a range of surgical procedures to treat eye diseases. These surgeries include:

• Cataract Surgery: Cataract surgery involves removing a cloudy lens and replacing it with a clear artificial intraocular lens. This restores clear vision and may reduce dependency on spectacles.

• Glaucoma Surgery: Glaucoma surgery aims to lower eye pressure to reduce further damage to the eye nerve. Glaucoma surgeries include trabeculectomy, tube implant surgery, minimally invasive glaucoma surgery and laser procedures.

• Retinal Surgery: Retinal detachment, macular holes, or diabetic retinopathy may require specialised procedures such as vitrectomy or laser photocoagulation to preserve or restore vision.

• Strabismus Surgery: Strabismus surgery corrects misaligned eyes by adjusting the eye muscles to improve one’s appearance and binocular vision.

• Eyelid Surgery: Ptosis surgery [3] and blepharoplasty address droopy eyelids or excess skin, enhancing both function and aesthetics.

Management of Eye Conditions

Ophthalmologists play an important role in diagnosing and managing sight-threatening eye conditions. These conditions often progress over time and may significantly affect vision and quality of life if not properly treated. Here are some examples of complex conditions and their management approaches:

• Glaucoma: A group of diseases characterised by eye nerve damage, often due to high eye pressure. Management typically includes regular monitoring of glaucoma tests, medications to reduce eye pressure, and surgical procedures like trabeculectomy, tube implant surgery or minimally invasive glaucoma surgery (MIGS).
• Diabetic Retinopathy: Poorly controlled diabetes damages the blood vessels in the retina, resulting in irreversible visual loss in advanced cases. Management of this condition includes regular dilated retinal examination, laser treatments, and injections to reduce retinal swelling.

• Macular Degeneration: The deterioration of the central retina (macula) is a common cause of vision loss in older adults. When there is associated swelling of the macula due to leakage from abnormal blood vessels,  anti-VEGF injections [4] are given to shrink the abnormal blood vessels and reduce macula swelling. Repeated injections long-term may be required to prevent further loss of vision.
• Corneal Diseases: Conditions like keratoconus or corneal scarring impair the cornea’s ability to focus light properly. Management includes corneal cross-linking, laser treatments, and corneal transplant.
• Pediatric Eye Disorders:  Issues such as amblyopia (lazy eye) and strabismus (misaligned eyes) often develop in childhood. Management of these conditions involves customised treatment plans that may include surgeries or corrective lenses.
• Dry Eyes: This occurs when tear production is insufficient, when the tears evaporate too quickly, or when the tear composition is abnormal. There are many causes of dry eyes,  including ageing, certain medications, lack of sleep, excessive screen time, environmental factors, and underlying conditions like autoimmune diseases or hormonal changes. Management includes artificial tears (eye drops or ointment) and punctal plugs (to block the drainage of tears to the nose, hence increasing the volume of tears on the ocular surface).
• Blepharitis: Inflammation of the eyelids, often caused by bacterial infection, result in eye redness, irritation, and sometimes eyelid infection. Management of blepharitis includes warm compress, eyelid hygiene, antibiotic ointments or eyedrops, topical steroid eye drops, and vitamin supplements. 

Reasons to Visit an Eye Specialist in Singapore

Caring for your eyes is essential to maintaining optimal vision and preventing long-term complications. While some eye issues may seem minor, they can be early signs of more severe conditions. If you or a loved one are experiencing any vision changes or abnormal eye symptoms, it is best to see an ophthalmologist as early treatment can prevent irreversible damage.

Here are some situations where visiting an eye specialist is recommended:

• Routine eye examinations: Regular eye tests and check-ups are important to monitor any vision changes and catch issues early. For those over the age of 40 years, an eye review at least every 2-4 years is advisable, while for those over the age of 65 years, an eye review at least every 1-2 years is advisable. If you have a family history of eye diseases (eg. glaucoma), or if you have diabetes, an annual eye examination is recommended.
• Experiencing vision changes or problems: Those experiencing symptoms such as floaters, blurry vision, or difficulty seeing at night may have underlying conditions such as cataract, refractive errors, or retinal problems, and should see an eye specialist as soon as possible.
• Eye pain: Eye pain and discomfort such as redness and itchiness could signify eye infections, glaucoma, blepharitis, or other conditions.
• Eye injury or trauma: Injuries to the eye such as blunt trauma, chemical exposure, or scratches may heal on their own but can also cause lasting damage. Those who experience such eye injuries should visit an eye specialist to get an eye examination.
• Medical conditions: Those with chronic medical conditions such as diabetes should be monitored regularly by an ophthalmologist as they can lead to eye issues [5] such as diabetic retinopathy, diabetic macular edema, cataract, and glaucoma.
• Vision problems in children: Parents should pay attention to vision issues in children such as squints or difficulty reading as these may be a consequence of amblyopia (lazy eyes) or myopia. 

When to Seek Immediate Attention from an Eye Specialist

Certain eye conditions can indicate a serious emergency that requires immediate medical attention. If you experience any of the following symptoms, it's crucial to consult an eye specialist as soon as possible:

• Sudden vision loss: Losing vision suddenly in one or both eyes can indicate serious issues such as retinal detachment, stroke, or a blockage in the blood vessels supplying the eye. Emergency intervention is essential to prevent permanent visual loss.
• Flashes of light or floaters: Seeing flashes of light or an increase in floaters (small spots or lines in your vision) could suggest retinal tears, retinal detachment or vitreous haemorrhage. These conditions require immediate attention to preserve vision.
• Severe eye pain: Severe, sharp, or persistent eye pain may be a sign of serious conditions, including glaucoma, an eye infection, or a foreign object in the eye. Immediate care is needed to prevent complications.
• Trauma or injury to the eye: Accidents or sports injuries can cause damage to the eye and the surrounding structures, requiring immediate medical attention
• Acute glaucoma [6]: A sudden increase in eye pressure can cause severe pain and irreversible vision loss if not treated immediately.
• Retinal detachment: A medical emergency where the retina separates from the back of the eye, leading to a potential loss of vision.

Choosing an Eye Specialist in Singapore 

When selecting an eye specialist in Singapore, it’s important to consider factors such as credentials and experience. Ensure that the ophthalmologist is accredited by the Singapore Medical Council (SMC), which guarantees that the specialist has met the necessary standards to practice in Singapore. 

Additionally, you should look for a specialist with experience in the specific area of your concern, whether it’s glaucoma, retina, or cornea. A specialist with advanced training who focuses on the latest treatments and technologies will be equipped to provide the best care for eye issues and conditions. 

Dr Chelvin Sng is a qualified ophthalmologist in Singapore specialising in glaucoma, cataracts, and general ophthalmology. Known for her patient-centric approach, Dr. Sng uses advanced technology and offers personalised treatment plans to meet each patient's individual needs, ensuring optimal eye health outcomes. Contact us today to book an eye screening or appointment. 

Cost of Visiting an Eye Specialist in Singapore

The cost of seeing an eye specialist in Singapore can vary between different clinics. On average, private clinics charge a consultation fee, in addition to charges for examination procedures and investigations. Higher fees may apply for specialist consultations requiring many diagnostic tests. Fees for consultation and investigations are generally lower at public hospitals, especially with subsidies for Singapore citizens and Permanent Residents, but waiting times for appointments may be longer.

If eye procedures are required, such as surgeries for cataract, glaucoma and retinal detachment, additional charges would apply. Eye clinics in Singapore typically charge within the Ministry of Health recommended guidelines for these procedures. Occasionally, the charges may exceed the Ministry of Health guidelines if the procedures are of exceptional complexity or if they are performed after-office-hours.

Eligible Singaporeans and Permanent Residents can use MediSave [7] for certain eye-related surgeries to offset the procedure costs. Many private health insurance plans also offer coverage for specialist consultations, diagnostic tests, and surgeries. It’s important to check the specifics of your plan for coverage details if you are required to undergo treatment for eye issues.

Preventative Eye Care Tips

Taking proactive steps to care for your eyes is essential in maintaining good vision and preventing potential issues as you age. While some factors like genetics may be beyond our control, adopting healthy habits can significantly reduce the risk of developing eye conditions. 

Here are some tips to protect your vision, including strategies to reduce screen time, nutrition advice for maintaining eye health, and lifestyle adjustments. By incorporating these preventative measures into your daily routine, you can reduce eye strain, maintain good vision and improve your quality of life.

• Follow the 20-20-20 rule [8]: To reduce eye strain, every 20 minutes, look at something 20 feet away for 20 seconds. This gives your eyes a break and helps prevent fatigue caused by prolonged screen time.
• Ultraviolet light filters: Ultraviolet light filters and wearing hats to block the ultraviolet rays from entering the eyes can reduce the incidence of certain eye diseases, including cataract, pterygium and age-related macular degeneration.
• Healthy foods: A diet rich in vitamins A, C, E, omega-3 fatty acids, and antioxidants is essential for maintaining eye health. Foods like carrots, leafy green vegetables, fish, and nuts are excellent for preserving vision.
• Stay hydrated: Proper hydration is essential for maintaining tear production and preventing dry eyes. Drink plenty of water throughout the day.
• Regular exercise: Engaging in regular physical activity can help reduce the risk of conditions like high blood pressure and diabetes, both of which can affect your vision.
• Quit smoking: Smoking increases the risk [9] of developing eye diseases such as cataract and age-related macular degeneration (AMD). Quitting smoking significantly reduces these risks.

Conclusion

Timely and proactive eye care is vital for preventing long-term vision problems. Conditions like cataract, glaucoma, and diabetic retinopathy can develop slowly and without noticeable symptoms until the advanced stages of the disease. Regular eye checkups help detect such conditions early.

Even if you do not have any current eye issues, scheduling routine eye exams with a qualified ophthalmologist is essential. Be proactive about your eye health and visit an eye specialist regularly, especially if you are over 40, have a family history of eye disease, or experience symptoms such as blurred vision, eye discomfort, or sensitivity to light.

Frequently Asked Questions (FAQs)

How often should I visit an eye specialist?

For those over 40 years, an eye review at least every 2-4 years is recommended, and for those over 65 years, an eye review at least every 1-2 years is recommended. If you have risk factors (family history of eye diseases or conditions like diabetes), you should visit an ophthalmologist annually.

How should I prepare for an appointment with an ophthalmologist?

To prepare for an ophthalmologist appointment, it is advisable to bring any relevant medical reports, referral letters, and medications. If you wear contact lenses, you should stop wearing them for a few days before your appointment. If pupil dilation is required to examine the retina, avoid driving for 4-6 hours after the eye review and wear sunglasses to minimise glare. 

How is an ophthalmologist different from an optometrist or optician?

An ophthalmologist is a medical doctor who can perform surgery and prescribe medications, while an optometrist provides eye exams, prescribes corrective lenses, and can diagnose certain eye conditions. An optician fits and dispenses eyeglasses and contact lenses based on prescriptions from an ophthalmologist or optometrist. Ophthalmologists, optometrists and opticians work closely together to help patients achieve the best vision and eye health. 

Is eye surgery safe?

Modern eye surgeries, such as cataract removal, LASIK, or minimally invasive glaucoma surgery, are generally safe. However, as with any surgery, there are potential risks that your ophthalmologist will discuss with you before performing any procedure.

References 

1. Singapore National Eye Centre. (n.d.). Singapore’s eye health. Singapore National Eye Centre from https://www.snec.com.sg/giving/singapores-eye-health
2. National University Hospital (NUH). (n.d.). Cataract. National University Hospital. Retrieved from https://www.nuh.com.sg/care-at-nuh/outcome-of-our-care/cataract
3. Koka K, Patel BC. Ptosis Correction. [Updated 2023 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK539828/
4. Kovach, J. L., Schwartz, S. G., Flynn, H. W., Jr, & Scott, I. U. (2012). Anti-VEGF Treatment Strategies for Wet AMD. Journal of ophthalmology, 2012, 786870. Retrieved from: https://doi.org/10.1155/2012/786870
5. National Institute of Diabetes and Digestive and Kidney Diseases. (n.d.). Diabetic eye disease. U.S. Department of Health and Human Services. Retrieved from https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/diabetic-eye-disease#:~:text=loss%20from%20diabetes%3F-,What%20is%20diabetic%20eye%20disease%3F,poor%20vision%20or%20even%20blindness.
6. WebMD. (n.d.). Acute angle-closure glaucoma. WebMD LLC. Retrieved from https://www.webmd.com/eye-health/acute-angle-closure-glaucoma
7. Ministry of Health Singapore. (n.d.). Medisave. Singapore Ministry of Health. Retrieved, from https://www.moh.gov.sg/managing-expenses/schemes-and-subsidies/medisave
8. Medical News Today. (2018, September 25). What to know about blepharitis. Medical News Today Retrieved from https://www.medicalnewstoday.com/articles/321536
9. U.S. Food and Drug Administration. (2020, September 16). How smoking can contribute to vision loss and blindness. U.S. Department of Health and Human Services. Retrieved from https://www.fda.gov/tobacco-products/health-effects-tobacco-use/how-smoking-can-contribute-vision-loss-and-blindness

Cataracts are a significant health concern, especially as we age, and in Singapore, they are one of the leading causes of vision impairment among older adults. By the age of 70, nearly 95% of people are likely to develop cataracts [1], which cloud the eye’s natural lens and lead to symptoms like blurry vision, difficulty seeing at night, and sensitivity to light. This condition progresses slowly, and while ageing is the primary cause, factors like prolonged UV exposure, smoking, diabetes, and certain medications can accelerate cataract formation. Given Singapore’s year-round tropical climate, with intense UV exposure, the risk of developing cataracts is even more pronounced.

The impact of cataracts on daily life cannot be overstated. What begins as subtle blurring of vision or increased glare can gradually lead to difficulties in performing everyday tasks such as reading, driving, or recognising faces. Left untreated, cataracts can severely impair vision, diminishing quality of life and independence for many elderly individuals.

Understanding the condition is crucial to proper eye health management, especially since cataracts are inevitable as one ages. While surgery is an effective treatment once cataracts develop, it is essential to focus on preventive measures that can help delay their onset or progression. This blog will explore the lifestyle changes and habits you can adopt to protect your eyes and reduce the severity of cataracts, which can empower you to take proactive steps toward maintaining healthy vision.

Proactive Steps to Protect Your Eyes from Cataracts

Although cataracts are a common result of ageing, there are several ways you can actively protect your eyes and reduce the severity of the condition. By incorporating simple yet effective lifestyle changes, you can help delay the onset of cataracts and keep your vision clear for longer. 

1. Eat a Nutrient-Rich Diet

One of the most important areas to focus on is your diet, as what you eat can significantly impact your eye health. Foods rich in antioxidants, such as vitamin C, vitamin E, lutein, and zeaxanthin, help protect the eyes from oxidative stress [2], which is a major contributor to cataract formation. These antioxidants neutralise free radicals that can damage the lens of the eye, which helps slow down or prevent the clouding that leads to cataracts.

• Vitamin C and E: Research has shown that a higher intake of vitamin C can slow cataract progression [3]. Oranges, strawberries, bell peppers, and broccoli are excellent sources. Vitamin E, which protects cells from oxidative damage [4], can be found in almonds, sunflower seeds, and spinach.

• Lutein and Zeaxanthin: These carotenoids, found in dark leafy greens like spinach, kale, and collard greens, are known to accumulate in the retina and lens of the eye, which offers natural protection against light-induced damage. Studies suggest that diets rich in these nutrients are associated with a lower risk of cataracts [5].

• Omega-3 fatty acids: found in fish such as salmon, mackerel, and sardines, Omega 3 fatty acids, have been linked to reduced inflammation in the eyes and may help protect against cataract formation [6]. 

By making small adjustments to your daily eating habits and focusing on nutrient-rich foods, you can significantly enhance your eye health and reduce the severity of cataracts in the long term.

2. Wear Sunglasses to Protect Your Eyes from UV Damage

Wearing sunglasses isn’t just a summer fashion statement—it’s one of the most effective ways to protect your eyes from cataracts, particularly in regions with high UV exposure like Singapore. Prolonged exposure to ultraviolet (UV) light can damage the lens of your eyes, contributing significantly to cataract formation [7]. The harmful UVA and UVB rays from the sun lead to oxidative stress in the eye,which can  accelerate the breakdown of proteins in the lens, eventually resulting in cloudiness of the lens or cataract [8].

To effectively prevent this, wearing sunglasses can help protect the eyes from the sun’s harmful UVA and UVB rays [9]. When purchasing sunglasses, look for a UV400 label, which guarantees maximum protection from UV radiation. Many sunglasses, even the affordable ones, offer this level of defense. It’s important to note, though, that polarisation alone doesn’t provide UV protection—it reduces glare but doesn’t block UV rays. Therefore, ensure that the sunglasses you choose are labelled with both UV protection and polarisation if you are aiming for optimal protection​ and comfort. 

Additionally, wraparound sunglasses or those with wider frames offer better coverage by preventing UV rays from entering from the sides. Pairing your sunglasses with a wide-brimmed hat for added shade can further reduce UV exposure and protect not just your eyes but the delicate skin around them​. 

By making the habit of wearing UV-protective sunglasses a part of your daily routine, especially during peak sunlight hours, you can significantly reduce the severity of cataracts and maintain good vision for years to come​. 

3. Quit Smoking to Lower Cataract Risk

Smoking has long been associated with a higher risk of various health problems, and cataracts are no exception [10]. Numerous studies have shown a strong link between smoking and cataract formation, primarily due to the oxidative stress caused by the chemicals found in cigarettes [11]. Smoking increases the amount of free radicals in the body, which leads to oxidative damage to the eye’s lens, hastening the breakdown of proteins and promoting cloudiness—key factors in cataract development.

In fact, research indicates that smokers are at a significantly higher risk of developing cataracts compared to non-smokers [12]. One study found that heavy smokers (those smoking more than 15 cigarettes a day) are up to three times more likely to develop cataracts than those who have never smoked [13]. 

Even for those who smoke less frequently, the risk is still elevated. Smoking doesn't only affect the lens of the eye but also reduces the levels of antioxidants like vitamin C in the body, which play a crucial role in protecting the eye from oxidative stress​. 

The good news is that quitting smoking can significantly reduce your cataract risk over time. Studies show that former smokers begin to reduce their risk after quitting, and within 10 to 20 years, their risk levels can approach those of non-smokers [14]. This means that it’s never too late to quit, as doing so will not only benefit your overall health but also protect your eyesight in the long term​. 

By quitting smoking, you give your body a chance to recover from oxidative stress and prevent further damage to your eyes, effectively reducing your chances of developing cataracts and other vision-related issues.

4. Protect Your Eyes from Injury

Preventing eye injuries is a crucial yet often overlooked step in protecting your vision and reducing the risk of cataracts. Physical trauma to the eye can lead to the development of cataracts, sometimes immediately after the injury or years later [15]. This risk is especially high for individuals engaged in activities like sports, DIY projects, or jobs that involve exposure to hazardous materials or high-impact tools.

Wearing appropriate protective eyewear, such as safety goggles or face shields, is essential to prevent injury. These safety measures are particularly important during activities like home repairs, construction work, or even gardening, where flying debris or sharp objects can cause serious harm to the eyes. Additionally, individuals working in environments with chemicals or small particles should use specialised protective eyewear designed to block out these potential hazards.

Even for everyday activities, it’s important to exercise caution. For example, using power tools or operating machinery without proper eye protection can lead to serious injuries that can cause cataract formation. By incorporating protective eyewear into daily routines where eye injuries are a risk, individuals can greatly reduce their chances of developing cataracts due to trauma.

Adopting these preventive measures not only protects against injuries but also contributes to overall long-term eye health, reducing the need for future medical interventions related to trauma-induced cataracts or other injuries.

 

5. Limit Your Alcohol Intake to Reduce Cataract Risk

Excessive alcohol consumption has been consistently linked to an increased risk of developing cataracts [16]. While moderate alcohol consumption may not significantly heighten the risk, heavy and long-term drinking can contribute to cataract formation due to its impact on oxidative stress, dehydration, and nutritional deficiencies in the body.

When alcohol is metabolised, it produces harmful by-products known as free radicals. These free radicals damage cells and tissues, including the proteins in the lens of the eye, leading to the cloudiness characteristic of cataracts. Additionally, excessive alcohol consumption can deplete the body’s  antioxidants, such as vitamins C and E, which are essential for protecting the eye from oxidative damage [17]. Dehydration from alcohol can also negatively affect the eyes, leading to dryness and irritation, which can further increase the risk of cataracts.

Research has shown that people who regularly drink large quantities of alcohol are more likely to develop cataracts earlier in life compared to those who drink moderately or abstain altogether [18]. By reducing your alcohol intake and drinking in moderation, you can significantly delay the onset of cataracts and protect your long-term vision health.

6. Keep Your Blood Sugar in Check to Protect Your Eyes

Maintaining healthy blood sugar levels is essential for preventing cataracts, especially for individuals with diabetes. High blood sugar levels can cause damage to the lens of the eye, which can accelerate the formation of cataracts [19]. This occurs because excess sugar in the blood can convert to sorbitol, a sugar alcohol that accumulates in the lens. When this happens, the lens swells, resulting in the lens becoming cloudy and leading to cataract development over time.

For people with diabetes, this risk is even more pronounced. Studies show that individuals with poorly controlled diabetes are more likely to develop cataracts at an earlier age compared to those without diabetes or those who have well-managed blood sugar levels [20]. Monitoring blood sugar levels through diet, exercise, and medication can significantly reduce the risk of cataracts in diabetic patients​. 

Even for individuals without diabetes, keeping blood sugar in check is a crucial preventative measure. High sugar intake and spikes in blood glucose can still impact eye health, which makes it crucial to adopt a diet that is rich in whole grains, fruits, and vegetables, and low in processed sugars​. 

7. Get Regular Eye Exams

One of the most effective ways to protect your vision and detect cataracts early is through regular eye screenings. Cataracts develop gradually, often without noticeable symptoms in the beginning, which makes annual eye check-ups crucial. Timely surgical intervention to remove the cataract prevents further vision impairment and maintains good eyesight.

During an eye exam, your ophthalmologist can detect early signs of cataracts, long before they become a significant issue. This is especially important for individuals over the age of 60, those with diabetes, or those with a family history of eye conditions, as they are at a higher risk for cataracts. Annual exams allow your eye doctor to monitor changes in your lens, assess overall eye health, and recommend treatments or lifestyle adjustments to slow down the progression of cataracts​. 

When cataracts are very advanced, cataract surgery may be more complex and may involve a higher risk of complications. Hence it is not advisable to allow cataracts to become too advanced before removing them. 

By scheduling yearly eye exams, you can not only detect cataracts but can also ensure early detection of other potential eye issues such as glaucoma or macular degeneration​. So make it a habit to visit your eye care professional annually to safeguard your eyesight and ensure early diagnosis and treatment.

Take Charge of Your Eye Health

Cataracts may be a common part of ageing, but they are not inevitable. By taking proactive steps such as adopting a nutrient-rich diet, protecting your eyes from UV radiation, quitting smoking, and limiting alcohol consumption, you can significantly reduce the severity of cataracts or delay the onset of cataracts. Additionally, managing your blood sugar levels and undergoing regular eye exams play a crucial role in detecting cataracts early, allowing for timely intervention that can help slow their progression and preserve vision for longer. 

Remember, early intervention is key. By making these lifestyle changes and staying committed to annual check-ups, you empower yourself to protect your vision and maintain clarity for years to come. Vision is one of our most vital senses, and safeguarding it with these preventative measures ensures that you can continue enjoying the world with clear, healthy eyesight well into your later years.

References 

1. Hashemi, Hassan, et al. “Global and Regional Prevalence of Age-Related Cataract: A Comprehensive Systematic Review and Meta-Analysis.” Eye, vol. 34, no. 8, Aug. 2020, pp. 1357–70. PubMed Central, https://doi.org/10.1038/s41433-020-0806-3. 
2. Diet and Nutrition. https://www.aoa.org/healthy-eyes/caring-for-your-eyes/diet-and-nutrition?sso=y#:~:text=Researchers%20have%20linked%20eye%2Dfriendly,a%20lot%20of%20other%20foods . Accessed 8 Oct. 2024. 
3. “Eating Foods High in Vitamin C Cuts Risk of Cataract Progression by a Third.” American Academy of Ophthalmology, 23 Mar. 2016, https://www.aao.org/newsroom/news-releases/detail/vitamin-c-cuts-cataract-risk. 
4.  Ching Kuang Chow. “Vitamin E and Oxidative Stress.” Free Radical Biology and Medicine, vol. 11, no. 2, Jan. 1991, pp. 215–32. ScienceDirect, https://doi.org/10.1016/0891-5849(91)90174-2. 
5. “Lutein/Zeaxanthin for the Treatment of Age-Related Cataract.” JAMA Ophthalmology, vol. 131, no. 7, July 2013, pp. 843–50. PubMed Central, https://doi.org/10.1001/jamaophthalmol.2013.4412. 
6.  Zhang, Yi, et al. “Association between Dietary Inflammation Index and Cataract: A Population-Based Study from NHANES 2005–2008.” Frontiers in Nutrition, vol. 11, Apr. 2024. Frontiers, https://doi.org/10.3389/fnut.2024.1379317. 
7.  Roberts, Joan E. “Ultraviolet Radiation as a Risk Factor for Cataract and Macular Degeneration.” Eye & Contact Lens, vol. 37, no. 4, July 2011, pp. 246–49. PubMed, https://doi.org/10.1097/ICL.0b013e31821cbcc9. 
8. Varma, Shambhu Dayal, et al. “Role of UV Irradiation and Oxidative Stress in Cataract Formation. Medical Prevention by Nutritional Antioxidants and Metabolic Agonists.” Eye & Contact Lens, vol. 37, no. 4, July 2011, p. 233. www.ncbi.nlm.nih.gov, https://doi.org/10.1097/ICL.0b013e31821ec4f2. 
9. “Do Sunglasses Actually Protect Your Eyes?” Cleveland Clinic, https://health.clevelandclinic.org/do-sunglasses-protect-your-eyes. Accessed 8 Oct. 2024.
10. Kulkarni, Aryan, and Shashank Banait. “Through the Smoke: An In-Depth Review on Cigarette Smoking and Its Impact on Ocular Health.” Cureus, vol. 15, no. 10, p. e47779. PubMed Central, https://doi.org/10.7759/cureus.47779.  Accessed 8 Oct. 2024. 
11. Ye, Juan, et al. “Smoking and Risk of Age-Related Cataract: A Meta-Analysis.” Investigative Ophthalmology & Visual Science, vol. 53, no. 7, June 2012, pp. 3885–95. PubMed, https://doi.org/10.1167/iovs.12-9820. 
12. Lindblad, Birgitta Ejdervik, et al. “Smoking Cessation and the Risk of Cataract: A Prospective Cohort Study of Cataract Extraction among Men.” JAMA Ophthalmology, vol. 132, no. 3, Mar. 2014, pp. 253–57. PubMed, https://doi.org/10.1001/jamaophthalmol.2013.6669. 
13. Kulkarni, Aryan, and Shashank Banait. “Through the Smoke: An In-Depth Review on Cigarette Smoking and Its Impact on Ocular Health.” Cureus, vol. 15, no. 10, p. e47779. PubMed Central, https://doi.org/10.7759/cureus.47779.  Accessed 8 Oct. 2024. 
14. Lindblad, Birgitta Ejdervik, et al. “Smoking Cessation and the Risk of Cataract: A Prospective Cohort Study of Cataract Extraction among Men.” JAMA Ophthalmology, vol. 132, no. 3, Mar. 2014, pp. 253–57. PubMed, https://doi.org/10.1001/jamaophthalmol.2013.6669. 
15.  Okoye, Godwin S., and Bharat Gurnani. “Traumatic Cataract.” StatPearls, StatPearls Publishing, 2024. PubMed, http://www.ncbi.nlm.nih.gov/books/NBK594251/. 
16. Chua, Sharon Y. L., et al. “Alcohol Consumption and Incident Cataract Surgery in Two Large UK Cohorts.” Ophthalmology, vol. 128, no. 6, June 2021, pp. 837–47. PubMed Central, https://doi.org/10.1016/j.ophtha.2021.02.007. 
17.  Wu, Defeng, and Arthur I. Cederbaum. “Alcohol, Oxidative Stress, and Free Radical Damage.” Alcohol Research & Health, vol. 27, no. 4, 2003, pp. 277–84. PubMed Central, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6668865/. 
18.  Piotr Kanclerz; Idan Hecht; Raimo Tuuminen. Is Occasional Alcohol Drinking and Smoking Related to the Development of Age-Related Cataract? https://iovs.arvojournals.org/article.aspx?articleid=2792895 
19. Cataracts and Diabetes | ADA. https://diabetes.org/health-wellness/eye-health/curious-about-cataracts#:~:text=What%20Causes%20Cataracts,accelerate%20the%20development%20of%20cataracts. Accessed 8 Oct. 2024.
20. Becker, Claudia, et al. “Cataract in Patients with Diabetes Mellitus—Incidence Rates in the UK and Risk Factors.” Eye, vol. 32, no. 6, June 2018, pp. 1028–35. www.nature.com, https://doi.org/10.1038/s41433-017-0003-1. 

Vision is one of our most cherished senses, and maintaining eye health is undeniably crucial. Amongst the myriad of eye conditions that can threaten our vision, glaucoma and cataracts stand out as two of the most common and potentially debilitating. 

Glaucoma and cataracts are significant public health concerns in Singapore, each affecting a substantial portion of the population, especially the elderly. Approximately 3% of people over the age of 50 in Singapore have glaucoma, with this percentage rising to nearly 10% for those over 70 [1]. More concerning is that most glaucoma sufferers are often unaware of their condition, as early glaucoma usually does not have symptoms, earning it the moniker “the silent thief of sight.” Cataracts are even more prevalent, with data showing that nearly 95% of people over the age of 70 are affected [2]. 

Glaucoma is associated with damage to the eye nerve and is often (but not always) associated with increased eye pressure. It progresses slowly and is usually asymptomatic until significant vision loss occurs. On the other hand, cataracts involve clouding of the eye’s natural lens, which results in a gradual decline in vision that can make everyday activities increasingly challenging.

Understanding the differences between glaucoma and cataracts is crucial for patients and healthcare providers alike. In the following sections, we will delve deeper into the causes, symptoms, diagnosis, and treatment options for both glaucoma and cataracts and provide a comprehensive guide to managing these vision-threatening conditions.

What is Glaucoma?

Glaucoma is a group of eye diseases characterised by damage to the eye nerve, which is crucial for transmitting visual information from the eye to the brain. The primary cause of this damage is usually elevated eye pressure, although glaucoma can occur even with normal eye pressure levels. The most common form of glaucoma is primary open-angle glaucoma, where the drainage canals in the eye become clogged over time, which causes increased eye pressure. Another form of glaucoma, angle-closure glaucoma, occurs when the iris blocks the drainage angle completely and causes an increase in eye pressure. The increase in eye pressure is usually gradual, but rarely, the eye pressure in angle-closure glaucoma can increase rapidly and suddenly.

The symptoms of glaucoma can vary significantly depending on the type and stage of the disease. In its early stages, primary open-angle glaucoma and primary angle-closure glaucoma typically have no symptoms, hence regular eye exams are essential for early detection. As the disease progresses, patients may notice peripheral vision loss, which can deteriorate to tunnel vision and, eventually, total irreversible blindness if untreated. Rarely, when the eye pressure in angle-closure glaucoma increases suddenly and rapidly, patients can present with symptoms such as severe eye pain, nausea, vomiting, blurred vision, and halos around lights. This is a medical emergency that requires immediate attention.

The exact causes of glaucoma are not entirely understood, but several risk factors have been identified, including age (people over 60 are at higher risk) [3], family history [4], ethnicity  (higher prevalence amongst African Americans, Asians, and Hispanics) [5], and certain medical conditions such as diabetes [6] and hypertension [7]. Other risk factors include prolonged use of corticosteroid medications [8], severe eye injuries, and thinner corneas (the transparent structure located at the front of the eye).

What are Cataracts?

Cataracts are a common eye condition characterised by the clouding of the eye’s natural lens, which lies behind the iris and the pupil. This clouding can result in a decrease in vision, as the lens becomes less transparent, scattering and blocking light as it enters the eye. Cataracts develop gradually and can affect one or both eyes. They are the leading cause of blindness [9] worldwide and are primarily associated with ageing. In Singapore, 80% of people have cataracts by the age of 60 years[10]. 

The primary symptoms of cataracts include blurry vision, difficulty seeing at night, sensitivity to light and glare, seeing halos around lights, fading or yellowing of colours, and double vision in a single eye. These symptoms can significantly impact daily activities such as reading, driving, and recognising faces, reducing the overall quality of life. Initially, stronger lighting and eyeglasses can help deal with the vision problems caused by cataracts, but as the condition progresses, surgical intervention becomes necessary.

Cataracts are primarily caused by ageing [11], as proteins in the lens break down and clump together, forming cloudy areas. Other factors contributing to the development of cataracts include diabetes [12], smoking [13], excessive alcohol consumption [14], prolonged exposure to ultraviolet sunlight [15], and the use of certain medications like corticosteroids [16]. Eye injuries, radiation therapy, and genetic predisposition can also increase the risk of developing cataracts.

What are some key differences between glaucoma and cataracts? 

We have highlighted some differences between glaucoma and cataracts in the table below:

Symptom/Sign	Glaucoma	Cataracts
Vision Changes	Gradual loss of peripheral vision, which may not be noticeable in the early stages	Cloudy or blurry vision
Noticeable Symptoms	Often asymptomatic until the glaucoma is advanced	Blurry vision, difficulty seeing at nightsensitivity to light and glare, seeing halos around lights, fading or yellowing of colours, and double vision in a single eye
Advanced Stages	Loss of central vision	Loss of central vision

A comprehensive examination by an ophthalmologist is crucial for a definitive diagnosis, allowing timely intervention to prevent severe vision loss.

Can cataracts cause glaucoma?

Most of the time, cataracts do not directly cause glaucoma, but there are instances where they can be associated with each other. It is not uncommon for elderly persons to have both cataracts and glaucoma. In certain situations, cataracts can exacerbate glaucoma. For example, very advanced cataracts can block the eye’s drainage system, resulting in increased eye pressure [17] and angle closure glaucoma. In addition, some types of glaucoma, such as secondary glaucoma, can result from conditions that might also cause cataracts, such as eye inflammation or trauma [18].

Moreover, the treatment of one condition can sometimes impact the other. For instance, cataract surgery can sometimes help lower eye pressure in glaucoma patients [19], which potentially reduces their need for glaucoma medications. Conversely, glaucoma surgery might exacerbate the development of a cataract [20]​. 

Which is more serious, glaucoma or cataract?

While cataracts are usually a reversible cause of poor vision, glaucoma is generally considered more serious as damage to the eye nerve is irreversible, and this results in irreversible vision loss if left untreated. The vision loss from glaucoma is typically gradual and asymptomatic in the early stages, which makes regular eye examinations crucial for early detection and management. Once vision is lost due to glaucoma, it cannot be restored.

In contrast, while cataracts significantly impact one’s quality of life, they are typically treatable with surgery. Cataract surgery, which involves removing the cloudy lens and replacing it with an artificial one, is highly successful in restoring vision. Unlike glaucoma, the vision impairment caused by cataracts can be effectively reversed through surgical intervention​. 

Can you still get glaucoma after cataract surgery?

Yes, it is possible to develop glaucoma after cataract surgery. Cataract surgery can lower eye pressure and benefit glaucoma patients, but there are also instances where it can contribute to the development or exacerbation of glaucoma.

• Postoperative eye pressure elevation: one of the potential complications after cataract surgery is an increase in eye pressure [21], which can lead to glaucoma. Factors such as inflammation, residual lens material, or other postoperative issues can contribute to elevated eye pressure, which makes regular monitoring essential for those at risk​. 
• Malignant glaucoma: a rare but serious condition, known as malignant glaucoma [22], can develop after cataract surgery. This occurs when the aqueous humour (the fluid in the front of the eye) flow is misdirected, which causes a sudden and severe increase in eye pressure. This form of glaucoma requires immediate medical attention and can be challenging to manage​. 
• Pre-existing conditions: patients who already have glaucoma are at a higher risk [23] for complications following cataract surgery. Special considerations and additional postoperative care are often required to ensure the best outcomes and to prevent the failure of prior glaucoma surgeries like trabeculectomy​ . 

Can glaucoma cause sudden blindness?

Yes, glaucoma can cause sudden blindness, particularly in the case of acute angle-closure glaucoma [24]. This type of glaucoma occurs when the drainage angle of the eye becomes suddenly blocked, which results in a rapid increase in eye pressure. This condition is a medical emergency and can result in total blindness within a matter of days if not treated immediately. Symptoms of an acute angle-closure glaucoma attack include severe eye pain, headache, nausea, vomiting, blurred vision, and seeing halos around lights​. 

Open-angle glaucoma, the more common form of glaucoma worldwide, usually progresses more slowly and does not typically cause sudden blindness. However, without treatment, it can still lead to significant and irreversible vision loss over time​. 

Managing and Treating Glaucoma and Cataracts

Early detection is crucial for managing both glaucoma and cataracts effectively. Regular eye examinations can help identify these conditions in their initial stages, which can help ensure timely intervention and prevent severe vision loss. For glaucoma, early detection is vital as the disease often progresses without noticeable symptoms. Regular screening, especially for those at higher risk—such as individuals over 60, those with a family history of glaucoma, and certain ethnic groups—can help catch the disease before significant damage occurs​. 

Similarly, cataracts develop gradually, and early detection through comprehensive eye examinations can help manage symptoms and determine the appropriate time for surgery. Identifying cataracts early allows patients to make lifestyle adjustments and consider surgical options before their vision significantly impacts daily activities​. Here are the treatment options for both conditions:

• Glaucoma: treatment for glaucoma primarily focuses on lowering eye pressure to prevent further eye nerve damage. This can be achieved through medications (typically eye drops), laser treatment, or surgical procedures. Medications help reduce eye pressure by decreasing the production of aqueous humour or improving its outflow. Laser treatments, such as trabeculoplasty, can enhance the drainage of eye fluid. In more advanced cases, surgical options like trabeculectomy or the implantation of drainage devices may be necessary. 
• Cataracts: the primary treatment for cataracts is surgical removal of the cloudy lens, which is replaced with an artificial intraocular lens (IOL). Cataract surgery is highly successful and commonly performed as a day surgery procedure. There are various types of IOLs available, including monofocal, multifocal, and extended-depth-of-focus lenses, which can address different vision needs​. 

Managing Glaucoma and Cataracts Together

For patients with both glaucoma and cataracts, managing these conditions requires careful consideration. When a glaucoma patient requires cataract surgery, there are typically two options: performing cataract surgery alone or combining it with glaucoma surgery.

• Cataract surgery alone: in some cases, performing cataract surgery alone can help reduce eye pressure, particularly in patients with mild to moderate angle-closure glaucoma. Removing the cataract can improve the outflow of aqueous humour, which helps lower eye pressure and reduce the need for glaucoma medications​. 
• Combined surgery: for patients with more advanced glaucoma or those who require additional eye pressure control, combining cataract surgery with glaucoma surgery can be beneficial. Procedures such as minimally invasive glaucoma surgeries (MIGS) can be performed together with cataract surgery. This combined approach can provide better eye pressure management and reduce the need for multiple surgeries. MIGS, in particular, are often favoured for their safety and efficacy when combined with cataract surgery​. 

Conclusion: Proactive Eye Care for Glaucoma and Cataracts

Glaucoma and cataracts are both common causes of vision loss. Glaucoma, often called the “silent thief of sight,” can lead to irreversible vision loss if not detected and managed early. Cataracts, while also detrimental to vision, are easily treated with vision-restoring cataract surgery. The solution to these eye health issues lies in proactive and early detection.

For patients dealing with both conditions, integrated treatment plans are essential. Options include standalone cataract surgery or combined procedures that address both glaucoma and cataracts simultaneously, tailored to the patient's specific needs.

Prioritising eye health through regular check-ups and being aware of the symptoms of these conditions can prevent severe vision loss and help maintain a good quality of life. By taking proactive steps and seeking timely medical advice, individuals can effectively manage and treat glaucoma and cataract.

References 

1. ​Singapore Epidemiology Of Eye Diseases. https://www.snec.com.sg:443/research-innovation/key-programme-singapore-epidemiology-of-eye-diseases.  Accessed 14 June 2024.  
2. ​Singapore Epidemiology Of Eye Diseases. https://www.snec.com.sg:443/research-innovation/key-programme-singapore-epidemiology-of-eye-diseases.  Accessed 14 June 2024. 
3. Glaucoma. (n.d.). Retrieved June 10, 2024, from https://www.aoa.org/healthy-eyes/eye-and-vision-conditions/glaucoma?sso=y 
4. Glaucoma: Family inheritance? - glaucoma research foundation. (2024, January 10). https://glaucoma.org/articles/glaucoma-family-inheritance 
5.  Siegfried, C. J., & Shui, Y.-B. (2022). Racial disparities in glaucoma: From epidemiology to pathophysiology. Missouri Medicine, 119(1), 49–54. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9312450/ 
6. Song, B. J., Aiello, L. P., & Pasquale, L. R. (2016). Presence and risk factors for glaucoma in patients with diabetes. Current Diabetes Reports, 16(12), 124. https://doi.org/10.1007/s11892-016-0815-6 
7.  Nislawati, R., Taufik Fadillah Zainal, A., Ismail, A., Waspodo, N., Kasim, F., & Gunawan, A. M. A. K. (2021). Role of hypertension as a risk factor for open-angle glaucoma: A systematic review and meta-analysis. BMJ Open Ophthalmology, 6(1), e000798. https://doi.org/10.1136/bmjophth-2021-000798 
8.  Feroze, K. B., Zeppieri, M., & Khazaeni, L. (2024). Steroid-induced glaucoma. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK430903/ 
9. Cicinelli, M. V., Buchan, J. C., Nicholson, M., Varadaraj, V., & Khanna, R. C. (2023). Cataracts. The Lancet, 401(10374), 377–389. https://doi.org/10.1016/S0140-6736(22)01839-6 
10. ​Singapore epidemiology of eye diseases. (n.d.). Retrieved June 11, 2024, from https://www.snec.com.sg:443/research-innovation/key-programme-singapore-epidemiology-of-eye-diseases 
11. Nizami, A. A., Gurnani, B., & Gulani, A. C. (2024). Cataract. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK539699/ 
12. Kiziltoprak, H., Tekin, K., Inanc, M., & Goker, Y. S. (2019). Cataract in diabetes mellitus. World Journal of Diabetes, 10(3), 140–153. https://doi.org/10.4239/wjd.v10.i3.140 
13. CDCTobaccoFree. (2023, March 20). Vision loss, blindness, and smoking. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/campaign/tips/diseases/vision-loss-blindness.html 
14.  Gong, Y., Feng, K., Yan, N., Xu, Y., & Pan, C.-W. (2015). Different amounts of alcohol consumption and cataract: A meta-analysis. Optometry and Vision Science: Official Publication of the American Academy of Optometry, 92(4), 471–479. https://doi.org/10.1097/OPX.0000000000000558 
15. Linetsky, M., Raghavan, C. T., Johar, K., Fan, X., Monnier, V. M., Vasavada, A. R., & Nagaraj, R. H. (2014). Uva light-excited kynurenines oxidize ascorbate and modify lens proteins through the formation of advanced glycation end products. Journal of Biological Chemistry, 289(24), 17111–17123. https://doi.org/10.1074/jbc.M114.554410 
16. Steroids and vision: Side effects, symptoms, and more. (2019, April 29). Healthline. https://www.healthline.com/health/steroids-and-vision 
17. Can a cataract increase the pressure within the eye? (2014, February 21). American Academy of Ophthalmology. https://www.aao.org/eye-health/ask-ophthalmologist-q/cataract-increase-pressure 
18. Secondary glaucoma—Glaucoma research foundation. (2023, October 11). https://glaucoma.org/types/secondary-glaucoma 
19. https://fyra.io. (n.d.). Cataract surgery and iop. Glaucoma Today. Retrieved June 10, 2024, from https://glaucomatoday.com/articles/2013-may-june/cataract-surgery-and-iop 
20. Cataracts and glaucoma—Glaucoma research foundation. (2024, January 10). https://glaucoma.org/articles/cataracts-and-glaucoma 
21. https://fyra.io. (n.d.). Elevated iop after cataract surgery. Glaucoma Today. Retrieved June 10, 2024, from https://glaucomatoday.com/articles/2007-may-june/0507_07.html 
22. Malignant glaucoma: Background, pathophysiology, epidemiology. (2023). https://emedicine.medscape.com/article/1205609-overview 
23. https://fyra.io. (n.d.). Cataract surgery in high-risk glaucoma patients. Glaucoma Today. Retrieved June 10, 2024, from https://glaucomatoday.com/articles/2015-may-june/cataract-surgery-in-high-risk-glaucoma-patients 
24. Khazaeni, B., Zeppieri, M., & Khazaeni, L. (2024). Acute angle-closure glaucoma. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK430857/
    
    
    
    

In recent decades, there has been a rise in certain eye diseases globally, driven by factors such as an ageing population, increased exposure to digital screens, and lifestyle changes. This trend is concerning not only because of its implications for one’s quality of life but also due to the significant healthcare costs and resources required to address these conditions. Common eye diseases include age-related macular degeneration (AMD) [1], cataracts [2], diabetic retinopathy [3], and glaucoma [4], which can lead to visual impairment and, in severe cases, blindness. Additionally, the prevalence of digital eye strain, characterised by symptoms such as dry eyes, eye irritation, and difficulty in focusing, has surged in correlation with the growing use of computers and smartphones.

The burgeoning concern over eye health issues in the modern world has led to an intensified search for effective preventive measures and treatments. Among the myriad options explored, dietary supplements have gained considerable attention as a potential solution. This growing interest is propelled by the promise that supplements, rich in vitamins, minerals, and antioxidants, offer significant benefits for eye health, potentially reducing the risk of age-related diseases and alleviating symptoms of digital eye strain.

The allure of dietary supplements lies in their perceived ease of use and accessibility, as they provide a non-invasive option for individuals seeking to enhance their ocular health proactively. With the market flooded with products claiming to support vision and protect against eye diseases, consumers are increasingly drawn to the convenience of supplementing their diet with these targeted nutrients.

Moreover, the shift towards preventive healthcare and a growing emphasis on holistic well-being have contributed to the popularity of dietary supplements. As individuals become more health-conscious, there is a greater inclination to seek out natural or nutritional means to maintain and improve health, including eye health. This trend is supported by the broader cultural move towards organic and natural products, which aligns with the preference for supplements derived from food sources or those that mimic natural dietary patterns.

However, the enthusiasm for dietary supplements also raises questions about their efficacy, the validity of manufacturer claims, and the potential for misinformation. The body of research on the impact of dietary supplements on eye health is extensive. Yet, the mixed results highlight the need for an in-depth understanding of when and how these supplements can be beneficial. 

As such, this article seeks to explore the current scientific evidence regarding the role of dietary supplements in eye health while addressing key questions about their effectiveness and the potential for supplements to mitigate the rising tide of eye health issues. Through a careful review of research, we aim to provide a comprehensive overview of the utility of dietary supplements in the context of eye health, which will contribute to informed decision-making among consumers.

 

Our sense of vision is intricately linked to our ability to interact with the world, perform daily tasks, and enjoy the beauty of our surroundings. Eye health extends beyond the mere absence of disease and encompasses optimal functioning that allows individuals to engage fully in daily living, work, and social interactions.

Eye health is a critical component of overall health and well-being, significantly impacting one’s quality of life. Poor eye health not only limits personal independence but also increases the risk of accidents, contributes to social isolation, and can lead to significant psychological distress. Thus, it emphasises the essential nature of maintaining good vision for a fulfilling life.

A Glimpse into Common Eye Conditions

Several eye conditions impact the global population, challenging individuals and healthcare systems. Common eye conditions include:

• Age-related macular degeneration (AMD): AMD is the leading cause of vision loss among the elderly. It affects the macula, the part of the eye responsible for clear, central vision and crucial for tasks like reading and driving.
• Cataracts: cataracts occur when the lens in the eye becomes cloudy and are a principal cause of blindness worldwide, though cataract surgery can effectively restore vision.
• Diabetic retinopathy: diabetic retinopathy is a complication of diabetes caused by damage to the retinal blood vessels. If left untreated, it may even lead to blindness.
• Glaucoma: glaucoma is often (though not always) associated with elevated pressure inside the eye, which can damage the optic nerve and result in irreversible vision loss and blindness.
• Digital eye strain: with the digitalisation of modern life, prolonged screen time has led to an increase in symptoms such as eye discomfort, dryness, and difficulty focusing, collectively termed digital eye strain or computer vision syndrome.

Lifestyle factors play a significant role in the health of our eyes. Nutritional choices, physical activity levels, smoking, and screen time can all influence eye health, either mitigating or exacerbating the risk of developing conditions like AMD, cataracts, glaucoma, and diabetic retinopathy. A diet [5] rich in fruits, vegetables, and omega-3 fatty acids has been linked to a lower risk of eye diseases, highlighting nutrition's role in ocular health. Conversely, smoking [6] significantly increases the risk of AMD and cataracts, while excessive screen use contributes to digital eye strain. 

The Basis of Supplements for Eye Health

Dietary supplements have soared in popularity among consumers who believe they are the ultimate solution for maintaining eye health. They are heralded for their potential to strengthen vision and guard against ocular disorders. These supplements include a variety of vitamins, minerals, and antioxidants, each selected for their purported benefits to eye function and health. Here are the types of supplements commonly marketed for eye health and the theoretical rationale behind their use.

• Essential Vitamins (A, B, C, and E): essential vitamins such as Vitamin A, Vitamin C, and Vitamin E are cornerstone ingredients in eye health supplements [7]. Vitamin A [8] is crucial for maintaining vision, especially in low-light conditions, and for the cornea's health. Vitamin C [9] contributes to the health of ocular blood vessels and, along with Vitamin E, acts as an antioxidant to protect the eyes from oxidative damage.
• Vitamin B3: Vitamin B3, also known as niacin, has garnered attention for its potential neuroprotective effects [10] in managing glaucoma, a condition characterised by optic nerve damage and visual field loss. High-dose vitamin B3 supplementation is thought to support the health of nerve cells in the eye, possibly slowing the progression of glaucoma. However, while the therapeutic benefits of niacin are promising, its administration at high doses is not without risks. Patients undergoing such treatment may experience side effects, including gastric issues [11] like upset stomach or ulcers and an increased risk of liver dysfunction [12]. Consequently, regular monitoring through liver function tests is crucial for those on a high-dose vitamin B3 regimen to ensure safe and effective management of their condition.
• Minerals: zinc [13] is a mineral frequently included in eye health supplements due to its role in transporting Vitamin A from the liver to the retina, supporting melanin production, a pigment that protects the eyes. Selenium, another mineral, works synergistically with antioxidants to enhance their protective effects on eye health.
• Antioxidants: Lutein and Zeaxanthin [14] are carotenoids found in the retina and are known for their antioxidant properties. They help filter harmful high-energy blue light, thus protecting and maintaining healthy eye cells. Omega-3 fatty acids [15], particularly EPA and DHA found in fish oil, are included for their anti-inflammatory properties and role in maintaining cell membrane health in the retina. Research [16]  indicates that the omega-3 fatty acids found in fish oil could aid in alleviating dry eye symptoms due to their ability to reduce inflammation.

 

Theoretical Rationale Behind Using Supplements for Eye Health

The rationale for using dietary supplements to support eye health hinges on understanding how nutrients contribute to ocular function and the body's defence against eye diseases.

Role of nutrients in eye function: many nutrients in eye health supplements are integral to visual processes. For example, Vitamin A is essential for converting light into an electrical signal in the retina. Lutein and Zeaxanthin, concentrated in the macula, are critical for visual acuity and protecting the retina from oxidative stress.

Preventing oxidative stress: oxidative stress results from an imbalance between free radicals and antioxidants in the body, which can cause cell damage. The eye, particularly the retina, is highly susceptible to oxidative stress due to its high metabolic rate and exposure to light. Antioxidants [17] like Vitamins C and E, Lutein, and Zeaxanthin can neutralise free radicals and reduce the risk of age-related macular degeneration (AMD) and cataract formation.

Supporting blood flow and reducing inflammation: adequate blood flow to the eye is vital for delivering nutrients and oxygen while removing waste products. Omega-3 fatty acids are known to support the tiny blood vessels in the eye and have anti-inflammatory properties that might help in conditions like dry eye syndrome [18].

The basis for using dietary supplements for eye health rests on their content of vital nutrients known to support visual function, protect against oxidative stress, and promote overall ocular health. While the theoretical rationale is compelling, the effectiveness of these supplements in practice is subject to ongoing research and debate within the scientific community. It emphasises the importance of a balanced diet and healthy lifestyle choices in conjunction with any supplementation for eye health.

Review of Research on Supplements for Eye Health

The investigation into the efficacy of dietary supplements for eye health has been extensive, with numerous studies attempting to delineate the benefits and limitations of these interventions. Among the most significant contributions to the field are the Age-Related Eye Disease Studies (AREDS and AREDS2) [19], which have provided insights into how certain supplements can impact eye health, particularly in the context of age-related macular degeneration (AMD) and cataracts. This section offers a summary of these landmark studies, an analysis of the evidence regarding the efficacy of supplements for specific eye conditions, and a discussion of the limitations of existing research.

Age-Related Eye Disease Study (AREDS)

The original AREDS study [20], funded by the National Eye Institute, concluded that a specific combination of antioxidants (Vitamin C, Vitamin E, and Beta-carotene) and minerals (Zinc and Copper) could reduce the risk of AMD progression by about 25% over five years for those with intermediate or advanced disease.

Age-Related Eye Disease Study 2 (AREDS2)

A follow-up to the original study, AREDS2 [21] sought to optimise the AREDS formula by testing the addition of Lutein and Zeaxanthin (replacing Beta-carotene) and Omega-3 fatty acids. The study found that replacing Beta-carotene with Lutein and Zeaxanthin was more effective and safer. However, the addition of Omega-3 fatty acids did not provide additional benefits.

Analysis of Evidence for Specific Eye Conditions

• Age-related macular degeneration (AMD): the AREDS and AREDS2 studies provide the most substantial evidence for supplement efficacy in slowing the progression of AMD in individuals at high risk. The formulations identified in these studies are now widely recommended for intermediate or advanced AMD patients.
• Cataracts: while the original AREDS study suggested that supplements may reduce the risk of cataract progression, subsequent research, including AREDS2, produced mixed results. The consensus is that while certain nutrients may support overall eye health, the evidence is less compelling for cataract prevention [22].
• Dry eye syndrome: some studies [23] have indicated that Omega-3 fatty acids can help alleviate dry eye syndrome symptoms by reducing ocular surface inflammation. However, results are varied, and more research is needed to determine efficacy conclusively.
• General vision health: the evidence supporting the use of eye health supplements to prevent decline or improve vision is limited for the general population without a specific eye disease. Nutrition and lifestyle factors play a significant role, and supplements may not offer added benefits for those without specific nutrient deficiencies or pre-existing eye diseases.

Mixed Results and Limitations of Eye Supplements

The research on supplements for eye health is characterised by mixed results, which translates to several limitations in the field. These include variability in study designs, supplement formulations, and participant demographics, which makes it challenging to generalise findings. Furthermore, these supplements' long-term effects and optimal dosages require further investigation.

Critically, the efficacy of supplements must be considered in the context of overall diet and lifestyle choices. For individuals with balanced diets rich in fruits, vegetables, and Omega-3 fatty acids, the incremental benefits of supplementation may be minimal. Moreover, the potential for interactions with medications and the risk of excessive intake of certain nutrients emphasises the importance of consulting an experienced ophthalmologist before beginning any supplement regimen.

Remember, while certain supplements have shown promise in managing conditions like AMD and, to a lesser extent, dry eye syndrome, the evidence for their widespread use in preventing eye diseases or enhancing general vision health remains inconclusive. Supplements should never be relied upon as the primary source of nutrients and minerals in your diet. 

Guidelines for Supplement Use in Eye Health

The National Eye Institute (NEI), part of the U.S. National Institutes of Health, played a pivotal role in the Age-Related Eye Disease Study (AREDS and AREDS2), which informed much of the current guidance on supplement use for certain eye conditions. For individuals with intermediate or advanced age-related macular degeneration (AMD), the NEI recommends a specific formulation of antioxidants and minerals [24] (based on the AREDS2 findings) to slow the progression of the disease.

Ophthalmologists often follow these guidelines and consider individual patient needs, health status, and the latest research findings. They may recommend supplements for patients with specific nutritional deficiencies or those at high risk for certain eye conditions.

Tips for Consumers Considering Supplements for Eye Health

• Consult an ophthalmologist: before starting any supplement regimen, it is crucial to consult an ophthalmologist. They can provide personalised advice based on your health history, current condition, and the latest scientific evidence. Doing so will help ensure that supplements do not interact adversely with any medications you may be taking or exacerbate existing health issues.
• Choose quality products: the dietary supplement market is vast and not uniformly regulated, resulting in product quality and efficacy variations. Consumers should look for supplements that have undergone third-party testing by reputable organisations to ensure the product's purity, strength, and composition.
• Read labels carefully: understanding the ingredient list and dosage levels is essential. Look for products that contain the nutrients supported by research, such as those found in the AREDS and AREDS2 formulations for AMD. Avoid supplements with excessive amounts of vitamins and minerals, which can be harmful.
• Lifestyle considerations: supplements should not substitute for a healthy diet and lifestyle. A balanced diet rich in fruits, vegetables, and Omega-3 fatty acids is vital for maintaining eye health. Regular exercise, wearing sunglasses outdoors, and reducing screen time can also support ocular well-being.
• Be wary of outlandish claims: be sceptical of supplements that claim to cure or prevent eye diseases without scientific backing. Legitimate supplement manufacturers will provide information consistent with current research and guidelines.

Conclusion

Both promising findings and areas of uncertainty mark the scientific exploration of dietary supplements for eye health. Research, particularly landmark studies like AREDS and AREDS2, has illuminated the potential benefits of specific nutrient formulations in reducing the risk of AMD progression. High-dose Vitamin B3 supplementation may have a neuroprotective effect and can be offered to patients with advanced glaucoma who are deteriorating despite good eye pressure control. The liver function tests would need to be monitored for such patients. The evidence for the effectiveness of supplements in addressing other eye conditions, such as cataracts and general vision health, presents a mixed picture. 

As we distil the essence of our findings, it becomes evident that while supplements can support certain eye health challenges, they are not a universal solution. The efficacy of these supplements is most pronounced in individuals with specific conditions or nutritional deficiencies rather than as a blanket recommendation for the general population. This delineation highlights the importance of personalised healthcare advice and underscores the need for consumers to approach supplement use with a critical eye.

Consulting with an experienced ophthalmologist is imperative for making informed decisions about supplement use for eye health. These experts can provide guidance based on an individual’s health profile and needs, the latest research, potential interactions with existing medications, and the overall importance of diet and lifestyle. 

References 

1. Age-related macular degeneration (Amd) | national eye institute. (n.d.). Retrieved March 11, 2024, from https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/age-related-macular-degeneration#:~:text=Age%2Drelated%20macular%20degeneration%20(AMD)%20is%20an%20eye%20disease,the%20back%20of%20the%20eye). 
2. Cataract treatment & surgery in Singapore—Dr Chelvin Sng. (n.d.). Chelvin Sng Eye Center | Glaucoma | Cataract | Retina Specialist Singapore. Retrieved March 11, 2024, from https://www.drchelvinsng.com/cataract-treatment-in-singapore/ 
3.  Diabetic retinopathy | National Eye Institute. (n.d.). Retrieved March 11, 2024, from https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/diabetic-retinopathy#:~:text=Diabetic%20retinopathy%20is%20caused%20by,vessels%20all%20over%20the%20body. 
4. Glaucoma. (n.d.). Chelvin Sng Eye Center | Glaucoma | Cataract | Retina Specialist Singapore. Retrieved March 11, 2024, from https://www.drchelvinsng.com/glaucoma/ 
5. Diet and nutrition. (2023, April 6). American Academy of Ophthalmology. https://www.aao.org/eye-health/tips-prevention/diet-nutrition  
6. Kulkarni, A., & Banait, S. (n.d.). Through the smoke: An in-depth review on cigarette smoking and its impact on ocular health. Cureus, 15(10), e47779. https://doi.org/10.7759/cureus.47779 
7. Murkey, S. P., Agarwal, A., Pandit, P., Kumar, S., & Jaiswal, A. (n.d.). Unveiling the spectrum of ophthalmic manifestations in nutritional deficiencies: A comprehensive review. Cureus, 15(12), e50311. https://doi.org/10.7759/cureus.50311 
8. Sajovic, J., Meglič, A., Glavač, D., Markelj, Š., Hawlina, M., & Fakin, A. (2022). The role of vitamin A in retinal diseases. International Journal of Molecular Sciences, 23(3), 1014. https://doi.org/10.3390/ijms23031014 
9. How vitamin C affects your eyesight. (2022, December 1). NVISION Eye Centers. https://www.nvisioncenters.com/diet-and-eye-health/vitamin-c/ 
10. Bhartiya, S. (2022). Niacinamide and neuroprotection: The glaucoma holy grail. Journal of Current Glaucoma Practice, 16(3), 141. https://doi.org/10.5005/jp-journals-10078-1390 
11. Avenue, 677 Huntington, Boston, & Ma 02115. (2020, July 6). Niacin – vitamin b3. The Nutrition Source. https://www.hsph.harvard.edu/nutritionsource/niacin-vitamin-b3/ 
12. B-3 niacin oral: Uses, side effects, interactions, pictures, warnings & dosing - webmd. (n.d.). Retrieved March 27, 2024, from https://www.webmd.com/drugs/2/drug-58189/b-3-niacin-oral/details 
13.  4 essential vitamins for eye health. (2019, October 23). https://www.medicalnewstoday.com/articles/326758 
14. Mares, J. (2016). Lutein and zeaxanthin isomers in eye health and disease. Annual Review of Nutrition, 36, 571–602. https://doi.org/10.1146/annurev-nutr-071715-051110 
15. Wang, H., & Daggy, B. P. (2017). The role of fish oil in inflammatory eye diseases. Biomedicine Hub, 2(1), 1–12. https://doi.org/10.1159/000455818 
16. Poteet, J. (2017). From alpha to omega: How fatty acids fight dry eye: a better understanding of the mechanisms of action can help you prescribe these supplements--and educate patients. Review of Optometry, 154(5), 78–83. https://go.gale.com/ps/i.do?p=AONE&sw=w&issn=1930160X&v=2.1&it=r&id=GALE%7CA496644485&sid=googleScholar&linkaccess=abs 
17. Diet and nutrition. (n.d.). Retrieved March 11, 2024, from https://www.aoa.org/healthy-eyes/caring-for-your-eyes/diet-and-nutrition?sso=y 
18. Dry eye: Causes, treatment, and symptoms. (2018, January 11). https://www.medicalnewstoday.com/articles/170743 
19. Areds/areds2 clinical trials | National Eye Institute. (n.d.). Retrieved March 11, 2024, from https://www.nei.nih.gov/research/clinical-trials/age-related-eye-disease-studies-aredsareds2/about-areds-and-areds2 
20. The age-related eye disease study (Areds): Design implications AREDS report no. 1. (1999). Controlled Clinical Trials, 20(6), 573–600. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1473211/ 
21. Chew, E. Y., Clemons, T., SanGiovanni, J. P., Danis, R., Domalpally, A., McBee, W., Sperduto, R., & Ferris, F. L. (2012). The age-related eye disease study 2 (Areds2): Study design and baseline characteristics(Areds2 report number 1). Ophthalmology, 119(11), 2282–2289. https://doi.org/10.1016/j.ophtha.2012.05.027 
22. Sperduto, R. D., Hu, T. S., Milton, R. C., Zhao, J. L., Everett, D. F., Cheng, Q. F., Blot, W. J., Bing, L., Taylor, P. R., & Li, J. Y. (1993). The Linxian cataract studies. Two nutrition intervention trials. Archives of Ophthalmology (Chicago, Ill.: 1960), 111(9), 1246–1253. https://doi.org/10.1001/archopht.1993.01090090098027 
23. Liu, A., & Ji, J. (2014). Omega-3 essential fatty acids therapy for dry eye syndrome: A meta-analysis of randomized controlled studies. Medical Science Monitor : International Medical Journal of Experimental and Clinical Research, 20, 1583–1589. https://doi.org/10.12659/MSM.891364 
24. The right vitamins for age-related macular degeneration: Areds2 | brightfocus foundation. (n.d.). Retrieved March 11, 2024, from https://www.brightfocus.org/macular/article/vitamins-age-related-macular-do-you-have-correct-formula 

Natural remedies are not all faux. As people of science, we must pay tribute to traditional and aboriginal medication, upon which modern medicine was built. According to the World Health Organization [1], a conservative estimate of 40% of pharmaceutical products [2] are drawn from natural and traditional knowledge. 

With the rise of social media, the inevitable rise of misinformation tails closely behind. There has been an increase in “home remedies” on social media sites such as TikTok, many claiming to remedy or even improve vision-related issues. Medical professionals often do not have the opportunity to refute these trendy “home remedies”, which are often unsubstantiated and may even cause further harm.

In this article, we sat with Dr Chelvin to understand the extent to which these claims hold weight. 

Claim #1: Castor oil can help to treat dry eyes, floaters, cataracts, poor vision, and glaucoma

Castor oil [3], derived from the seeds of the castor bean plant, has a long history in traditional and folk medicine [4]. Recently, the resurgence of castor oil as a potential solution for eye-related issues has gained traction, thanks to influencers showcasing their experiences on TikTok.

Many TikTok influencers have uploaded videos showing the application of castor oil around their eyes. Some suggest that the benefits of castor oil include improved vision and reduced eye dryness. Some even claim that castor oil is effective in treating certain eye conditions such as cataract and glaucoma. 

Various community reports have claimed that castor oil has antimicrobial activity and is effective in stimulating uterine contraction and promoting lipid metabolism. However, to date, castor oil has only obtained FDA approval as a stimulative laxative [5].

Regarding eye health, below are some relevant studies.

Purported benefits	Explanation
A study [6] indicated that a nanoemulsion of brimonidine tartrate, prepared using castor oil along with Lipoid S75, Lipoid E80, and PF-68, showed potential for glaucoma treatment.	Brimonidine [7] is an established glaucoma medication and is the active ingredient that lowers eye pressure rather than castor oil. The conclusion that castor oil is effective in treating glaucoma is erroneous.
A study [8] found that using castor oil on the base of one eyelid twice a day for four weeks improved blepharitis-related symptoms.	Although the results of this solitary study seem promising, further research is necessary to validate the claims. Studies with larger sample sizes and longer follow-up durations are required to substantiate this claim.

Castor oil, which is widely available in grocery stores, may contain additives, such as preservatives or fragrances. These additives can be potentially harmful, mainly when applied to sensitive areas like the eyes or skin. Using castor oil with additives on the skin may result in irritation, redness, or allergic reactions, especially for individuals with sensitive skin. The delicate skin around the eyes is particularly susceptible to irritation, and exposure to additives in castor oil could lead to discomfort or inflammation. 

Moreover, if the oil comes into contact with the eyes, it may increase the risk of eye infections. In some cases, putting castor oil directly on the eyes can damage the transparent, dome-shaped cornea [9]. Additionally, commercially available castor oil has not been adequately sterilised; hence, using it as an eye drop increases your risk of eye infections.

Another common side effect of using castor oil as an eye drop is blurry vision, as it creates an oily layer over the tear film and ocular surface. 

Claim #2: Eye yoga improves vision and remedies age-related vision changes (presbyopia)

Eye yoga, also known as yogic eye exercises, includes a set of yoga flows (known as asanas) designed to enhance vision and alleviate eye strain. Below are some articles supporting the benefits of eye yoga: 

Purported benefits	Explanation
The Journal of Yoga [10] hypothesised that eye yoga works to bring down intraocular pressure [11] (IOP).	These hypotheses were not substantiated by any clinical trials. Therefore, they remain as baseless claims.
A study [12] with 60 subjects indicated that practising eye yoga reduced fatigue and eye tiredness.	The practice of eye yoga may have aided subjects to remain more focused and subsequently minimised stress levels. Consequently, these effects may help to reduce eye strain and fatigue as they are directly attributed [13] to stress.

Other alleged benefits have included eye yoga benefitting patients after cataract surgery, remedying age-related near vision changes, known as presbyopia [14], or forestalling the need for reading glasses. Scientific evidence supporting these claims is still lacking. We recommend consulting your ophthalmologist to ensure safety before implementing any eye yoga practice. 

Claim #3: Using homemade eye drops to remedy ocular issues 

Another common and dangerous practice is using homemade or unregulated eye drops. Many use homemade eye drops to soothe eye dryness, redness, or irritation. However, concocting homemade eye drops under non-sterile conditions and applying them to your eyes without adequate medical knowledge can cause serious ocular injury. Such adverse consequences include eye infection, allergy, or other complications. 

Purported benefits	Explanation
It has been claimed that tea tree oil [15] can eliminate Demodex mites [16] from the eyelashes. An overgrowth of these microscopic mites can lead to blepharitis, a condition characterised by itchy and swollen eyelids.	However, it remains controversial whether concentrations of tea tree oil between 5% and 50% are effective in treating Demodex blepharitis. Regardless, lower concentrations of tea tree oil are less likely to cause ocular irritation.

Applying essential oils directly to or around the eyes is associated with potential risks. Even in dilute concentrations, they can cause eye irritation, allergy, and damage to the ocular surface; whilst essential oils can be beneficial to human health [17], attempting to use them specifically to remedy eye-related issues can be disastrous. 

It is recommended to use HSA-approved and sterile eye drops [18] explicitly designed to treat ocular issues such as eye redness, dryness, or irritation. HSA-approved products undergo rigorous testing, therefore assuring their safety and efficacy. 

Claim #4: Raw meat or steak to heal black eyes 

This is not exactly a social media trend per se, but rather a misconception that has persisted for years. Initially seen on television, characters would reach out for steak or meat in their fridge to heal bruised or black eyes after intense combat. Soon, people began replicating these “behaviours”. 

It is important to note that this belief is not grounded in scientific evidence, as using a piece of steak is not only an ineffective remedy but can also be harmful. The rationale behind the practice is often misunderstood, as it's not the meat that contributes to healing but rather the application of coldness to the affected area.

The cold temperature provides therapeutic benefits by reducing swelling and promoting vasoconstriction [19], which can alleviate pain and bruising. However, the choice of a steak is questionable, as raw meat potentially contains harmful bacteria that can cause infections when applied to the delicate skin around the eye.

For a safe and effective alternative, use an ice pack instead, which helps you achieve the desired cooling effect without the risks associated with using raw meat. This would be a more hygienic and practical solution for managing a black eye and reducing swelling.

Takeaway 

In the age of social media, where trends and unverified remedies circulate rapidly, it is crucial to approach eye care cautiously and discerningly. Numerous practices propagated across social media platforms, such as castor oil application, essential oil usage, Beezin' [20], using a hairdryer for eyelash curling, resorting to raw meat or steak for treating a black eye, and using homemade eyedrops have gained attention for their unsubstantiated claims. 

However, a closer look reveals that many of these practices lack scientific support and, in some cases, can be potentially harmful to ocular health. Protecting the health of your eyes requires informed decision-making and recognising that not all trends, no matter how popular, are grounded in scientific reality. 

Rather than relying on unverified and potentially hazardous trends, individuals should consult qualified eye care professionals, particularly ophthalmologists, for any eye-related concerns. 

An ophthalmologist possesses the expertise to provide accurate diagnoses and recommend safe and effective treatments for various eye conditions. If you have any eye-related concerns, please schedule an appointment with Chelvin Sng Eye Centre for individualised treatment options. 

References

1. World Health Organization. (n.d.). Traditional medicine has a long history of contributing to conventional medicine and continues to hold promise. Retrieved December 1, 2023, from https://www.who.int/news-room/feature-stories/detail/traditional-medicine-has-a-long-history-of-contributing-to-conventional-medicine-and-continues-to-hold-promise 

2. World Health Organization. (n.d.). WHO Global Centre for Traditional Medicine. Retrieved December 1, 2023, from https://www.who.int/initiatives/who-global-centre-for-traditional-medicine 

3. WebMD. (n.d.). Castor Oil: Health Benefits. Retrieved December 1, 2023, from https://www.webmd.com/diet/castor-oil-health-benefits 

4. Sharma, S. K., Singh, M., Narang, P., & Kaur, J. (2019). Castor oil: A potential bio-based polyol for polyurethane. Materials Today: Proceedings, 18, 4207–4212. https://doi.org/10.1016/j.matpr.2019.07.559 

5. National Center for Biotechnology Information. (2019). Castor Oil. In StatPearls [Internet]. Retrieved December 1, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK551626/#:~:text=Castor%20oil%20is%20most%20well,use%20as%20a%20stimulative%20laxative 

6. Salari, S., Khodayar, M. J., Feyzi, F., & Khatibi-Moghadam, H. (2012). Correlation between Mental Toughness and Academic Procrastination in a Sample of Iranian Medical Sciences Students. Basic and Clinical Neuroscience, 3(3), 49–55. https://www.eurekaselect.com/article/92034
7. Brimonidine (ophthalmic route) precautions (2023) Mayo Clinic. Available at:    https://www.mayoclinic.org/drugs-supplements/brimonidine-ophthalmic-route/precautions/drg-20067572?p=1#:~:text=Brimonidine%20eye%20drops%20is%20used,caused%20by%20minor%20eye%20irritations. (Accessed: 01 December 2023). 
8. Muntz, A., Sandford, E., Claassen, M., Curd, L., Jackson, A.K., Watters, G., Wang, M.T. and Craig, J.P., 2021. Randomized trial of topical periocular castor oil treatment for blepharitis. The ocular surface, 19, pp.145-150. Retrieved December 1, 2023, from https://www.sciencedirect.com/science/article/abs/pii/S1542012420300859?via%3Dihub 

9. Cleveland Clinic. (n.d.). Cornea. Retrieved December 1, 2023, from https://my.clevelandclinic.org/health/body/21562-cornea 

10. Sankalp et al. (2018) Effect of yoga-based ocular exercises in lowering of intraocular pressure in glaucoma patients: An affirmative proposition, International Journal of Yoga. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6134736/ (Accessed: 01 December 2023).

11. Machiele, R., Motlagh, M. and Patel, B. (no date) Intraocular pressure - StatPearls - NCBI Bookshelf, National Library of Medicine. Available at: https://www.ncbi.nlm.nih.gov/books/NBK532237/ (Accessed: 01 December 2023).
12. Kim, S.-D. (2016) Effects of yogic eye exercises on eye fatigue in undergraduate nursing students, Journal of physical therapy science. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4932063/ (Accessed: 01 December 2023).
13. Stress.org. (n.d.). How Stress Affects Your Vision. Retrieved December 1, 2023, from https://www.stress.org/how-stress-affects-your-vision#:~:text=Constant%2C%20severe%20stress%20levels%20and,and%20stress%2Drelated%20vision%20problems. 

14. SingHealth. (n.d.). Presbyopia. Retrieved December 1, 2023, from https://www.singhealth.com.sg/patient-care/conditions-treatments/presbyopia 

15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7388771/#:~:text=Authors'%20conclusions,to%20avoid%20induced%20ocular%20irritation .
16. Cleveland Clinic. (n.d.). Demodex (Face Mites). Retrieved December 1, 2023, from https://my.clevelandclinic.org/health/diseases/22775-demodex-face-mites 

17. Elshafie, H.S. and Camele, I. (2017) An overview of the biological effects of some Mediterranean essential oils on human health, BioMed research international. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5694587/  (Accessed: 01 December 2023). 

18. Health Sciences Authority. (Year). New Drug Approvals - July 2023. Retrieved December 1, 2023, from https://www.hsa.gov.sg/announcements/new-drug-approval/new-drug-approvals---july-2023 

19. Cleveland Clinic. (n.d.). Vasoconstriction. Retrieved December 1, 2023, from https://my.clevelandclinic.org/health/symptoms/21697-vasoconstriction 

20. Ophthalmology Times. (n.d.). Beezin: The Hazardous TikTok Trend Involving Burt’s Bees. Retrieved December 1, 2023, from https://www.ophthalmologytimes.com/view/beezin-the-hazardous-tiktok-trend-involving-burt-s-bees 

Increasing need for ophthalmologists in Singapore 

The field of ophthalmology is less well-known than other medical specialities. Many only come to hear of ophthalmology when they require the services of an ophthalmologist or are inspired to pursue the career of one. 

Unbeknownst to many, the need for ophthalmologists' services is progressively increasing in Singapore, with the prevalence of a myriad of eye conditions being a contributing factor: 

• About 66.67% [1] of Singaporean adults have visually significant cataracts, which were previously undiagnosed. 
• Glaucoma, the Silent Thief of Sight, affects 10% of Singaporeans and is undiagnosed in 50% of cases [2]. 
• Symptomatic dry eye disease affects around 12.3% [3] of Singaporeans.
• Singapore is labelled the Myopia Capital of the World [4], with a staggering increase in myopia in the last two decades.

The rising rate of certain eye diseases is partially attributed to poor eye health literacy. Whilst poor awareness is the fundamental factor, fear of seeking medical attention, and the lack of screening practices (almost half of Singaporeans do not abide by the recommended frequency of eye screening) are arguably the culprits behind these unfavourable statistics. 

Singapore is home to Southeast Asia's most prominent ophthalmologists, many of whom are leading researchers, innovators, and philanthropists who provide eyecare access to remote parts of the world and underprivileged communities. Given that Singapore is indeed a powerhouse for eyecare specialists, it remains a question of whether the proficiency of ophthalmologists will ever reflect upon the population’s health. 

Ophthalmologist vs. Optometrist vs. Optician in Singapore 

Ophthalmologists often work closely with optometrists and opticians to provide patients with holistic and optimal care. The roles and qualifications differ between ophthalmologists, optometrists, and opticians. Please refer to the table below to help you understand the differences between the different eye health professionals in Singapore.

Profession	Ophthalmologist	Optometrist	Optician
Qualification	5-Year Ophthalmology Residency Training with Subspecialty and Surgical Experience	Diploma in Optometry	Opticianry Diploma or Certificate
Perimeter of medical service	-- Diagnosing and treating ophthalmic diseases and conditions.  -- Conduct ocular surgery where necessary. -- Prescribing optical aids and medication.	-- Examine eyes to detect vision problems within remit of qualification.  -- Conduct eye screening. -- Prescribe and fit spectacles, contact lenses, and various optical aids. -- Refer patients to ophthalmologists for further management, especially if surgery or medications are required.	-- Perform visual examination. -- Dispensing and fitting visual aids within remit of qualification. -- May perform refraction on patients older than 8 years.  -- Refer patients to ophthalmologists for further management, especially if surgery or medications are required.

When should I visit an ophthalmologist in Singapore?

1. Visit an ophthalmologist for regular eye screenings 

One should visit the ophthalmologist to undergo regular eye screening. The frequency will differ by age and risk factors such as family history, prior eye injury, and underlying health conditions that may increase the risk of eye diseases and conditions. 

Below is the prescribed frequency by age:

• Age 3 and below: screening is done during scheduled paediatric appointments. 
• Between 3 to 19 years old: annual or bi-annual screenings. In Singapore, it is necessary that screening for myopia is done in these age groups, given they are prone to this condition.  
• Between 20 to 39 years old: if you have glasses or contact lenses prescribed, get your eye screening done annually for an updated prescription and to keep an eye on the progression of your condition. Additionally, you should undergo a comprehensive eye examination if you have a family history of eye diseases or an eye injury.
• Between 40 to 64 years old: at the age of 40, it is essential to obtain baseline screening to assess the condition of your eyes. For individuals aged between 40-54 years, you are advised to get a screening every 2 to 4 years, depending on your condition. For those aged 55-64 years, get an eye screening every 1-3 years. 

Additionally, patients with risk factors such as diabetes [5] and high blood pressure [6] require frequent review and assessment by an ophthalmologist. Whilst some health conditions pose risks to one’s vision, an eye screening may also reveal undiagnosed health conditions [7], such as heart conditions, cancer, and lupus. 

2. Visit an ophthalmologist when symptoms of eye conditions are present 

Self-diagnosing is not advised when you suspect your eye health is deteriorating. A few symptoms indicate that you may be suffering from an eye condition and require medical intervention from an ophthalmologist. 

These include:

• A recent increase in black spots in your vision, known as eye floaters [8]
• Persistent bumps and lumps in your eyelid 
• Dry eyes with consistent dependency on eye drops 
• Recurring itchiness and eye redness that affects your quality of life 
• Frequent eye discharge (typically yellowish or greenish) 
• Blurred vision
• Distortion of vision 

Some eye diseases, such as glaucoma, have no symptoms in the early stages. Hence, we should not undergo eye examinations only when we experience the symptoms above. Often, patients are unaware of their deteriorating eye health. Thus, it is crucial to undergo regular eye check-ups to detect eye diseases early so as to receive treatment early.

3. Visit an ophthalmologist when you are referred by a doctor or an optometrist 

You are advised to visit an ophthalmologist when suspected of an eye condition that requires further treatment. There are many factors guiding your choice of an ophthalmologist. 

Some would include: 

• Competence and experience: it is important to research the doctor’s expertise and qualifications before making a choice on your ophthalmologist. If you are seeking treatment for a more specialised eye condition, e.g., glaucoma, pay attention to the fellowship training that the ophthalmologist has received, which provided him/her with the subspecialty training and skills. In Singapore, many ophthalmologists receive subspecialty training abroad at world-renowned institutions. In addition, some Singaporean ophthalmologists are internationally renowned and have been recognised as global leaders in their field.
• Language: patients often seek doctors who can communicate well in their language of choice. However, translators are easily available in Singapore, so if your chosen ophthalmologist does not speak the same language as you, ensure that a translator is available. 
• Insurance: patients tend to seek ophthalmologists who are included in their insurance panels. However, insurance companies would still provide a degree of medical coverage for non-panel doctors, with the amount of coverage varying depending on your insurance company and the plan that you have purchased. Hence, do not despair if your chosen ophthalmologist is not on your insurance panel; speak with your insurance agent, and you may be pleasantly surprised that significant reimbursement is still available! 

What eye tests are usually conducted in Singapore? 

Depending on your condition, you may require one or more of the tests listed below:

Test	Purpose
Visual acuity tests	-- Assesses the sharpness of your vision. -- Letters or numbers on a chart are projected at a fixed distance away. -- The smallest line of letters that you can see will give an indication of how good your vision is.  -- Poor vision can be due to incorrect spectacles prescription, cataracts, age-related macular degeneration, and other eye diseases.
Visual field tests	-- Assesses your peripheral vision. -- People with glaucoma lose their peripheral vision first, and they often do not notice this until their central vision is affected. -- The visual field test will allow us to detect glaucoma as well as other diseases involving the eye nerve and the visual pathway in the brain.
Optical coherence tomography of the macula	-- Utilises light waves to obtain a high-resolution and detailed scan of your macula, the central part of the retina, which is responsible for central vision. -- This will detect diseases such as age-related macular degeneration, macular swelling due to diabetes, and central serous retinopathy.
Optical coherence tomography of the optic nerve	-- Optical Coherence Tomography uses light waves to obtain a high-resolution and detailed scan of your eye nerve. -- This will allow us to detect diseases involving the eye nerve, such as glaucoma.
Anterior segment optical coherence tomography	-- The anterior segment optical coherence tomography uses light waves to obtain a high-resolution scan of the drainage angle of the eye. -- This can detect angle closure, which increases the risk of glaucoma.
Refraction	-- Lenses are placed in front of your eye to improve your vision. -- The power of the lens, which is able to achieve the best vision, is recorded. -- To help you see more clearly, you can make a new pair of spectacles with this lens power.
Tonometry	-- The tonometry test measures the pressure in your eye. -- High eye pressure can be a sign of glaucoma.
Fundus and Optic Nerve Photography	-- A photograph of your retina and eye nerve is taken. -- Abnormalities in the appearance of your retina or eye nerve may indicate glaucoma, age-related macular degeneration, diabetic retinopathy, and other eye diseases.
Colour Vision	-- Assesses ability to distinguish colours. -- Assessed with the Ishihara chart. -- Abnormalities in colour vision can be hereditary or can indicate disease of your macula and eye nerve.
Amsler Grid	-- The Amsler grid is used to check for abnormalities in your central vision (e.g., distortion or dark patches in your vision) which can be caused by diseases of your macula.

Conclusion 

We hope this article has empowered you to take control of your eye health. As with any health condition, early detection provides the best opportunity to manage and prevent the progression of eye conditions and diseases. A competent ophthalmologist can perform a comprehensive eye examination and provide valuable advice on how to improve your eye health.  If you have not had a recent eye examination, do not put this off any further and make an appointment now. 

References

1. Chua, J. et al. (2017) Prevalence, risk factors, and impact of undiagnosed visually significant cataract: The Singapore Epidemiology of Eye Diseases Study, PloS one. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5271362/#:~:text=After%20age%2Dstandardization%20to%20the,CI%2C%204.79%E2%80%936.82%25)%20and (Accessed: 05 June 2023).
2. Singapore National Eye Centre (2022) Glaucoma: Eye under pressure. Available at: https://www.snec.com.sg/singvision-issue1-2022-glaucoma-eye-under-pressure (Accessed: 05 June 2023).
3. Tan , L.L., Morgan, P. and Cai , Z.Q. (2014) Prevalence of and risk factors for symptomatic ... - Wiley Online Library, Prevalence of and risk factors for symptomatic dry eye disease in Singapore. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/cxo.12210 (Accessed: 05 June 2023).
4. Ministry of Health Singapore (2019) Speech By Dr Lam Pin Min, Senior Minister Of State For Health, At The Opening Of The Singapore National Eye Centre’s Myopia Centre, 16 August 2019, Ministry of Health. Available at: https://www.moh.gov.sg/news-highlights/details/speech-by-dr-lam-pin-min-senior-minister-of-state-for-health-at-the-opening-of-the-singapore-national-eye-centre-s-myopia-centre-16-august-2019 (Accessed: 05 June 2023).
5. Centers for Disease Control and Prevention (2022) Diabetes and Vision Loss. Available at: https://www.cdc.gov/diabetes/managing/diabetes-vision-loss.html#:~:text=Eye%20diseases%20that%20can%20affect,way%20toward%20protecting%20your%20eyesight. (Accessed: 05 June 2023).
6. WebMD Editorial Contributors (2022) High Blood Pressure and Eye Disease, WebMD. Available at:https://www.webmd.com/hypertension-high-blood-pressure/guide/eye-disease-high-blood-pressure (Accessed: 05 June 2023).
7. Mukamal, R. (2022) 20 surprising health problems an eye exam can catch, Tips and Prevention. Available at: https://www.aao.org/eye-health/tips-prevention/surprising-health-conditions-eye-exam-detects (Accessed: 05 May 2023).
8. Mayo Clinic Staff (2022) Eye floaters, Mayo Clinic. Available at: https://www.mayoclinic.org/diseases-conditions/eye-floaters/symptoms-causes/syc-20372346 (Accessed: 05 June 2023).

The Ophthalmologist Power List Provides Insight to Singapore’s Leading Eye Specialists 

Click here to learn more about The Ophthalmologist’s Power List

The Power List from The Ophthalmologist magazine was first created in 2014 to honour and pay tribute to innovators, practitioners, researchers, and other significant authority figures in the field of ophthalmology. Every year, momentous strides are made in ophthalmic sciences, whether through new research, education, clinical practices, or leadership. To ensure contributions do not go unnoticed, these individuals are featured alongside their specific contributions on the Power List as the 100 Most Influential Figures in Ophthalmology. 

Readers are invited to place their nominations online along with nominees' contributions to research, innovation, teaching and mentoring, progressing practice, communication and advocacy, or humanitarianism. When nominations are closed, an independent panel of experts rigorously review the list of nominees before finalising the list of top ophthalmologists globally. 

It is important to note that the Power List is not necessarily definitive. Many eye specialists may have gone unnoticed or unnominated. It serves as a motivation and supplementation for many eye doctors to further pursue advancements in ophthalmology. As mentioned by Dr Andrew Bastawrous, Professor of Global Eye Health and Co-Founder and CEO of Peek Vision, the Power List has helped increase the profile of his work, enabling vision care to be made accessible in underserved communities around the world. 

Ophthalmology in Singapore 

Singapore continues to reach high rankings in various global health lists. It is important that doctors, researchers, and innovators are given credit where due, not just for their commitment to their country but for the relentless pursuit of making healthcare accessible to even the most remote communities worldwide.

Unbeknownst to many, Singapore is home to many of the top ophthalmologists worldwide. Behind the scenes, Singaporean health specialists continue to make advances in health technologies, humanitarian works, and relentless contributions to various new studies that change the trajectory of healthcare.

Most Singaporean ophthalmologists have received postgraduate fellowship training in an internationally renowned institute overseas as part of the Ministry of Health’s Social & Health Manpower Development Programme (SHMDP) initiative. This ensures that ophthalmologists in Singapore have a global perspective and are experienced in treating patients of other races and cultures. New surgical techniques are then adapted for the treatment of our Asian patients for the best possible surgical outcomes.   

The Ophthalmologist Power List 2023

This year, The Ophthalmologist celebrated their 10-year anniversary. To commemorate a decade of accumulating the best thought leaders and authority figures in the field, The Ophthalmologist sought nominations of individuals who had also consistently contributed and created an impact in the field of ophthalmology in the last 10 years. Dr Chelvin C. A. Sng is honoured to be amongst the 6 ophthalmologists from Singapore who have been included in The Ophthalmologist Power List 2023 and is the only Singaporean ophthalmologist in private practice to be featured on this year’s Power List. 

Click here to view The Ophthalmologist Power List 2023

In the 2023 feature, Dr Chelvin highlighted her breakthrough in the field of ophthalmology with the Paul Glaucoma Implant (PGI), which aims to improve the safety, predictability, and efficacy of tube implant surgery. As an inventor and researcher, she is proud to implant the PGI in her patients with good outcomes. She is also one of the first eye surgeons in Asia to perform minimally invasive glaucoma surgery (MIGS), which has provided patients with mild to moderate glaucoma a safe and effective alternative to glaucoma medications. 

Lending weight to The Ophthalmologist Powerlist are giants of the industry and internationally renowned ophthalmologists Dr Keith Barton and Sir Peng Tee Khaw – both of whom are Consultants at the prestigious Moorfields Eye Hospital and are recognised for their tremendous contributions to the realm of ophthalmology and in particular glaucoma. Dr Chelvin is proud to have trained under Dr Barton and Sir Khaw while pursuing a glaucoma fellowship at Moorfields Eye Hospital a decade ago. 

Women in Ophthalmology 

In 2021, The Ophthalmologist paid tribute to an all-female ophthalmologist list as an initiative to address gender disparities and imbalances. Additionally, it was also an initiative aimed to provide an opportunity to showcase the best female ophthalmologists in the field globally. Dr Chelvin was one of three female Singaporean ophthalmologists who made the list. 

Dr Chelvin shared her sentiments about the under-representation of female ophthalmologists and the need to inspire future generations of female ophthalmologists to pursue this field of work despite the gender-relevant challenges. 

Dr Chelvin also highlighted the need for female ophthalmologists to be heard, indicating the necessity for increased female representation. The Ophthalmologist has attempted to address potential biases in their Power List throughout the years. What was previously a list dominated by Caucasian and male ophthalmologists has today shifted to be a more balanced and comprehensive representation of significant contributors around the globe – with a healthy balance of the best female ophthalmologists from different races worldwide.

A study conducted in the US in 2022 revealed that female ophthalmologists now constitute approximately 25-30% of all ophthalmologists and 35-45% of trainees [1]. However, under-representation in positions of professional leadership, academic leadership, and ophthalmic surgical subspecialisation is prevalent in this field [2]. 

Some of the challenges faced by female ophthalmologists include:

• Reduced representation of top female ophthalmologists, thus increasing the possibility of the reluctance of junior female ophthalmologists to strive for positions in power within their organisation [3].
• Female ophthalmologists, as principal investigators in research, tend to receive fewer grants and funding in their early careers than their male counterparts [4]. 
• A significant wage disparity between female ophthalmologists and their male counterparts in clinical practice, academia, and salaried positions is prevalent in the field [5]. 
• As in every medical practice, female ophthalmologists in training are more prone to bullying or harassment from their peers and patients. Statistics also signify that female ophthalmologists are treated with less respect than their male counterparts [6]. 

Additionally, many women in ophthalmology dedicate more time to their children's development than male ophthalmologists [7]. An increased rate of women in ophthalmology succumbing to part-time roles to be more involved in childcare may also be observed. 

Click here to read more about Dr Chelvin’s interview. 

2022’s Top 100 Ophthalmologist Power List 

In 2022, a greater representation of Singaporean doctors was observed in 2022’s Top 100 Ophthalmologists Power List. Dr Chelvin made her 4th appearance alongside 5 other top Singaporean ophthalmologists. It was undoubtedly a significant milestone for the Singaporean medical community as numbers doubled from the previous year. This was the mark of the best eye doctors in Singapore, earning the recognition they deserved globally. 

The Future of Ophthalmology in Singapore 

It is Dr Chelvin’s desire that more women pursue a career in ophthalmology. However, she recognises that for this to happen, awareness of this field needs to be more widespread. Dr Chelvin also hopes to be part of the solution to provide more opportunities for female ophthalmologists in research, academia, or career opportunities. 

She hopes the proficiency of ophthalmologists in Singapore reflects improved eye health of the population. This includes fewer eye diseases, better practices, and increased eye screening. Our eyes are the windows to our soul, and sight is the most important of our five senses. Thus, taking care of our eyes will benefit our overall health. 

References

1. Hannah K. Gill, R. L.-M. (2022). An Eye on Gender Equality: A Review of the Evolving Role and Representation of Women in Ophthalmology. American Journal of Ophthalmology, 232-240.
2. Elizabeth A. Fairless, K. H. (2022). Ophthalmology Departments Remain Among the Least Diverse Clinical Departments at United States Medical Schools. Ophthalmology, doi: 10.1016/j.ophtha.2021.01.006.
3. Mona L. Camacci, A. L. (2020). Association Between Sex Composition and Publication Productivity of Journal Editorial and Professional Society Board Members in Ophthalmology. JAMA Ophthalmology, doi:10.1001/jamaophthalmol.2020.0164.
4. Ashvini K. Reddy, G. W. (2016). Representation of Women With Industry Ties in Ophthalmology. JAMA Ophthalmology, doi:10.1001/jamaophthalmol.2016.0552.
5. Jing Sasha Jia, A. L.-C. (2021). Gender Compensation Gap for Ophthalmologists in the First Year of Clinical Practice. Ophthalmology, 971-980.
6. Neeranjali S Jain, H. K.-M. (2020). Bullying and harassment in ophthalmology: a trainee survey. The New Zealand Medical Journal.
7. Kumar Saurabh, K. S. (2015). Personal and practice profile of male and female ophthalmologists in India. Indian Journal of Ophthalmology, 482-486.

Glaucoma is an eye condition characterised by damage to the eye nerve, which can result in vision loss and blindness. Glaucoma is also known as the “The Silent Thief of Sight”, as early glaucoma has no symptoms and by the time the patient notices any visual impairment, it is too late as the glaucoma is already advanced.

Another eye condition that can result in vision loss and blindness is cataract. As both glaucoma and cataract can result in vision loss, patients often mistake one condition for the other.

Glaucoma and cataract are two completely different diseases, with different treatment strategies. In this article, please allow me to address some common questions frequently posed by patients, including;

•   The differences between cataract and glaucoma

•   Whether surgery should be performed immediately after diagnosing glaucoma

•   The newest treatment for glaucoma

 What are some differences between cataract and glaucoma?

Cataract	Glaucoma
Caused by a cloudy lens in your eye	Caused by damage to the eye nerve, usually because the eye pressure is too high. If untreated, this leads to loss of vision and blindness
Vision loss associated with cataract is reversible after cataract surgery	Vision loss associated with glaucoma is permanent and irreversible even after surgery is performed
Affects the lens of the eye	Affects the eye nerve
Symptoms include cloudy and blurry vision, glare, and faded colours	Few or no symptoms in the early stages
Cataract surgery can be considered when the cataract affects your quality of life; surgery is usually not urgent because the vision loss due to a cataract is often reversible	Early diagnosis and treatment are important to prevent further permanent vision loss
Usually progresses slowly over years	Variable; damage to the eye nerve caused by glaucoma is usually slowly progressive but if the eye pressure is very high, the progression can be rapid
Treatment involves replacing the cloudy lens with an intraocular lens	Treatment involves either increasing the drainage of fluid from the eye or reducing fluid production within the eye, to lower the eye pressure

Both cataract and glaucoma can only be detected through regular detailed eye examinations.

What is the most common treatment for glaucoma?

Although glaucoma cannot be cured, there are various treatment options available to help prevent further vision loss and blindness. These treatment options are:

Medications

There are two types of medications for glaucoma: eye drops and oral medications. Eye drops are often the first line of treatment for glaucoma. Oral glaucoma medications are associated with significant systemic side effects (including kidney stones and metabolic acidosis), hence should be used short-term with close monitoring of kidney function, and are not appropriate for long-term consumption.

Glaucoma medications work by reducing the intraocular pressure within the eye by either lowering the production of fluid in your eye or by improving fluid drainage out of your eye.

Glaucoma eye drops that lower the production of fluid in your eye include:

• Beta-blockers
• Alpha-adrenergic agonists
• Carbonic anhydrase inhibitors
• Rho kinase inhibitors

Glaucoma eye drops that improve fluid drainage out of your eye include:

• Prostaglandin analogues
• Alpha-adrenergic agonists
• Rho kinase inhibitors
• Miotic or cholinergic agents (seldom prescribed as a glaucoma medication)

There are various side effects associated with topical glaucoma medications, including allergies, blurred vision, eye redness, and eye discomfort. You must be extremely compliant with your eye drop regime in order to prevent your glaucoma from progressing.

Surgery

Glaucoma surgery is an option if:

• Medications are unable to lower the eye pressure sufficiently
• The individual is unable to tolerate the side effects of medications
• Or if the individual is unable to comply with the strict medication regime

Types of glaucoma surgery in Singapore include:

• Laser therapy: laser trabeculoplasty is used to improve the drainage of fluid from your eye. Trans-scleral cyclophotocoagulation reduces the production of fluid in the eye.
• Trabeculectomy: during trabeculectomy, an opening is created on the sclera or the white part of your eye, allowing fluid to drain out of the eye.
• Tube implant surgery: during tube implant surgery, a tube is inserted into your eye to drain excess fluid.
• Minimally invasive glaucoma surgery (MIGS): during MIGS, microscopic devices are inserted into the eye through tiny incisions to increase fluid drainage from the eye. MIGS is usually combined with cataract surgery and has a very high safety profile.

Lifelong follow-up and monitoring are required to ensure that your glaucoma is not progressing.

It is important to note that glaucoma treatment is individualised, according to the severity of the glaucoma, the number of eye drops required to control eye pressure, age of the patient, and the patient’s preference.

What is the best treatment for glaucoma?

Choosing the best glaucoma treatment for each patient involves weighing the risk of treatment and the risk of vision loss from glaucoma.

Hence, the first line of treatment is usually glaucoma medications. If eye drops are able to control the patient’s eye pressure with minimal side effects, then the use of eye drops is continued as long as the glaucoma remains under control.

If the patient has both cataract and glaucoma, they could choose to undergo either cataract surgery alone, or combined cataract surgery with glaucoma surgery to reduce or eliminate the need for glaucoma eye drops. Numerous studies have shown that the risk of complications from combined cataract surgery and MIGS is similar to that from cataract surgery alone, while the eye pressure control from MIGS is lower.

Patients with mild to moderate glaucoma are at low risk of vision loss from glaucoma, and these patients are good candidates for MIGS which has a high safety profile. With careful patient selection, MIGS can potentially free this group of patients from glaucoma eye drops after the procedure [1].

Patients with advanced glaucoma may undergo conventional glaucoma surgery such as trabeculectomy and tube implant surgery as these are more effective at lowering intraocular pressure but are also associated with more potential complications.

What is the newest treatment for glaucoma?

MIGS is one of the newest treatment options for glaucoma. It uses microscopic devices and small incisions to lower the eye pressure and is considered a safer option compared to conventional glaucoma surgery. It also has a faster recovery time.

Different MIGS devices work in different ways, and they reduce eye pressure by either:

• Improving fluid drainage internally through the blood vessels
• Draining fluid externally out of your eyes
• Reducing the production of fluid in your eyes

All three mechanisms result in the reduction of eye pressure. This preserves the function of the eye nerve, thereby minimising vision loss and preventing blindness.

Can glaucoma be cured permanently?

There is no cure for glaucoma but if detected and treated early, further vision loss and blindness can be prevented. If you are in the high-risk group (e.g., aged over 55, family history of glaucoma, medical conditions such as high blood pressure and diabetes), you must have regular eye examinations to screen for glaucoma, the “silent thief of sight”. Ideally, regular eye examinations should start from the age of 40 years.

If you have any questions regarding glaucoma treatment, please feel free to drop me a message.

References

1. Dhingra, D., & Bhartiya, S. (2020). Evaluating glaucoma surgeries in the MIGS context. Romanian Journal of ophthalmology, 64(2), 85–95.
2. Sng CCA, Barton K (2018). Minimally invasive glaucoma surgery – coming of age. Br J Ophthalmol 2018; 102:1315-6. 

“I can't have glaucoma — I can still see clearly.” As an ophthalmologist with over 17 years of experience, I have encountered many glaucoma patients who do not have any symptoms, especially in the early stages of their condition.

More than 90%[1] of patients with glaucoma remain undiagnosed worldwide; detection is tremendously crucial, especially in the early stages – because once there is eye nerve damage, the loss in vision is irreversible.

Glaucoma is a leading cause of blindness globally, and is often poorly managed in developing nations: 

• WHO estimates that approximately 4.5 million people worldwide[1] are blind due to glaucoma
• Glaucoma accounts for moderate and severe visual impairment in 7.7 million people globally[2].

While this widespread disease cannot yet be cured, glaucoma treatment in Singapore is of paramount importance to prevent further irreversible visual loss.

If you’re living with glaucoma in Singapore, read on to find out more about this blinding condition and the available options for glaucoma treatment. 

What is glaucoma? 

Glaucoma is a disease that damages your eye nerve. The condition usually occurs when fluid (aqueous humour) builds up in your eye, therefore increasing the pressure in your eye, and eventually damaging the eye nerve.

Our eyes naturally create fluid that provides oxygen and nourishment to the rest of the eye. In a normal eye, as new fluid is produced within our eyes, the same amount of fluid drains out via our drainage angles. This process keeps the intraocular pressure (IOP) or eye pressure stable.

However, in eyes with glaucoma, the drainage angles do not drain fluid adequately, causing fluid to accumulate within the eye, increasing eye pressure and eventually damaging the eye nerve. 

If left untreated, glaucoma can eventually lead to permanent blindness. As early glaucoma does not have any symptoms, it is often not detected until it’s too late, when damage to the eye nerve is severe. Hence, glaucoma is often called “The Silent Thief of Sight”.

What are the types of glaucoma? 

Glaucoma can be a primary (not associated with other eye diseases) or secondary (associated with other eye diseases) condition.

It can be further categorised under open-angle (the drainage angles are open and fluid can easily enter the drainage pathway) and closed-angle glaucoma (the drainage angle is closed because the iris is contact with the cornea, hence preventing fluid from entering the drainage pathway).

Type of glaucoma	What it is
Primary open-angle glaucoma	This is the most common form of glaucoma worldwide. The drainage angle is open and fluid can easily enter the drainage pathway. However, the drainage pathway itself is not functioning well, hence reducing drainage of fluid from the eye.
Primary angle-closure glaucoma, or narrow-angle glaucoma	This occurs when the drainage angle is closed because of contact between the iris and the cornea. Hence, fluid is unable to enter the drainage pathway, resulting in increased eye pressure. In eyes with acute angle-closure, the drainage angles are completely closed, resulting in markedly raised eye pressure. This is a medical emergency which can cause rapid blindness and requires immediate treatment.
Normal-tension glaucoma, or low-tension glaucoma	This occurs when the eye nerve becomes damaged at normal levels of eye pressure. Normal tension glaucoma is associated with diseases such as high blood pressure, diabetes and sleep apnoea.
Secondary glaucoma	This occurs because an associated condition has resulted in increased eye pressure and damage to the eye nerve. Eye trauma, inflammation, medication use, and poorly controlled diabetes can cause secondary glaucoma. Traumatic glaucoma can occur immediately, or even years after an injury.
Pigmentary glaucoma	This is a type of open-angle glaucoma that occurs when small pigment granules on the iris are chafed off and become trapped in the eye’s drainage pathway.
Exfoliative glaucoma	This occurs when a white, flaky, dandruff-like material occludes the drainage pathway of the eye, increasing eye pressure.
Neovascular glaucoma	This condition arises when abnormal new blood vessels develop on the iris and over the drainage angles. These vessels damage the drainage pathway, preventing fluid from flowing out of the eye. Poorly controlled diabetes can result in neovascular glaucoma .
Uveitic Glaucoma	Inflammation within the eye damages and obstructs the drainage pathway in the eye, hence resulting in raised eye pressure. Steroid used to treat the eye inflammation can also obstruct the drainage pathway, further elevating eye pressure.
Congenital Glaucoma	This is a rare and often hereditary condition caused by the abnormal development of the drainage pathway in a child.

What are the symptoms of glaucoma?

Early glaucoma (open-angle glaucoma and chronic angle-closure glaucoma) often has no symptoms. Visual impairment might not be noticeable until the glaucoma is advanced. 

As the increase in eye pressure and the visual loss is gradual in most patients, it typically and initially presents as loss of peripheral vision. As the glaucoma progresses, one’s vision becomes increasing constricted, until the patient is eventually left with only a tiny central island of vision.

At this stage, the patient will only be able to see what is directly ahead of him/her.

In a minority of patients, the eye pressure increases suddenly to very high levels, resulting in acute glaucoma. This is often associated with closed angle glaucoma.

Open-angle glaucoma cannot be prevented. Closed-angle glaucoma, on the other hand, is preventable. In the early stages of the disease, a laser procedure called an iridotomy can potentially help to widen the drainage angles and prevent an increase in eye pressure. 

Early cataract surgery can also widen the drainage angles and has been shown in a large study[3] to be more effective in lowering the eye pressure and improving the vision compared with iridotomy. 

Is glaucoma common in Singapore?

In Singapore, glaucoma affects about 3% of those 40 and older, and nearly 10% of those aged 70 and above[4]. It is reported that while everyone has a 2.3% lifetime risk of glaucoma, first-degree relatives of glaucoma patients have a ten-fold increase in risk.

Here are the other risk factors for glaucoma:

• Older age
• Gender (Closed-angle glaucoma is more common in females)
• Race (Closed-angle glaucoma is more common in Chinese individuals)
• Short-sightedness / high myopia (Increases the risk of developing open-angle glaucoma)
• Long-sightedness (Increases the risk of developing closed-angle glaucoma)
• Prior eye injuries

• Medical conditions (eg. diabetes, hypertension)
• Co-existing eye diseases, such as inflammation and pigment dispersion
• Steroid use

Should I be worried if I have glaucoma?

Damage to the eye nerve in eyes with glaucoma cannot be reversed, so if you have risk factors for glaucoma, it is important to have annual eye examinations. Even if you do not have any of the above risk factors, it is recommended to have regular eye examinations after the age of 40. 

In addition, to keep your eyes healthy, I encourage the following: 

• Wear appropriately powered spectacles
• Wear sunglasses with UV protection
• Brighten your lighting at home and at work
• Exercise moderately 
• Eat a healthy, well-balanced diet with leafy green vegetables and rich in anti-oxidants

If you have both cataracts and glaucoma, you can opt for combined cataract and glaucoma surgery which will not only improve your quality of life but will also reduce or eliminate your need for glaucoma medications.

Some ophthalmologists undergo further subspecialty training (fellowships) to become glaucoma specialists. Early glaucoma may be difficult to diagnose, and a review by a Singaporean glaucoma specialist may be necessary for a definitive diagnosis of glaucoma to be made, and for the type of glaucoma to be identified. 

If you have risk factors for glaucoma or if you experience symptoms of acute glaucoma listed above, please visit your ophthalmologist immediately, as early glaucoma treatment is crucial in Singapore.

How is glaucoma tested in Singapore? 

When it comes to glaucoma screenings in Singapore, you can expect to undergo the following:

• Tonometry. This measures your eye pressure.

• Gonioscopy​. Your eye doctor places a special lens on your eye to determine whether you have open or closed angles. Anaesthetic eye drops will be given prior to the placement of the lens on your eye, making this examination quick and painless.

• Visual Fields Assessment. This test is carried out in a dark room with a white screen. Patients will be tasked to press a button when they see flashes of light, of varying intensities and sizes on this screen. This test assesses your peripheral vision, hence identifying any damage to the eye nerve.

• Eye nerve assessment. Your specialist will look at the back of your eye through a special lens to assess the health of your eye nerve. Photographs and specialised scans of the eye nerve may also be taken.

Glaucoma surgeons in Singapore are likely to employ various methods to diagnose glaucoma. 

How is glaucoma treated in Singapore?

Glaucoma treatment in Singapore often starts with prescription eye drops. 

Eye drops work by reducing the production of aqueous fluid, or by increasing fluid drainage. The use of daily eye drops is usually life-long, and compliance is crucial. Some patients may require several types of glaucoma eye drops in order to lower their eye pressure to an acceptable level. 

If glaucoma eye drops are not able to reduce the eye pressure sufficiently, if the patient is not compliant with the eye drop regime or if there are significant side effects from the eye drops, other treatment options for glaucoma in Singapore are: 

• Intravenous or oral anti-glaucoma medications might be prescribed to reduce the high eye pressure, but these should not be used long-term in view of the potential side effects on the body. 
• Glaucoma surgery
  • Tube implant surgery, where a device is inserted into your eye to allow excess fluid to drain out.
  • Trabeculectomy, where an opening is created for the fluid in the eye flow out onto the surface of the eye.
  • Minimally Invasive Glaucoma Surgery (MIGS), which involves using tiny incisions and/or microscopic devices to drain fluid out of the eye internally or externally.

Read: Is surgery always necessary to treat glaucoma? 

• Glaucoma laser treatment 
  • Selective Laser Trabeculoplasty (SLT), where a laser is used to increase the outflow of fluid from your eye.
  • Laser Iridotomy, where laser is used to create a microscopic hole in the iris to widen the angles in the eye, allowing more fluid to enter the drainage pathway. Laser iridotomy is usually performed in patients with angle-closure glaucoma.
  • Laser Iridoplasty, where laser burns on the peripheral iris widens the angles in the eye, allowing more fluid to enter the drainage pathway. Laser iridoplasty is used to treat eyes with plateau iris syndrome, a type of angle closure glaucoma.

It is important to tell your eye doctor if you have the following conditions or drug allergies, as it will affect the type of treatment you are suitable for:

• Any form of drug allergies (especially sulphur allergies)
• Heart disease (especially heart block, or heart failure)
• Kidney disease
• Asthma

Do note that glaucoma eye drops might have side effects, which may affect some patients more than others. It is important to inform your eye doctor if you are experiencing any side effects from glaucoma eyedrops and please follow your eye doctor’s instructions when administering these eye drops.

Can I use MediSave for Glaucoma treatment in Singapore?

Yes, part of the costs for surgery and laser procedures are Medisave-claimable depending on your condition. Please speak to our friendly staff for more information.

If you suspect that you might have glaucoma, there is no time to waste – see a glaucoma specialist as soon as possible. Early treatment of glaucoma can preserve vision. 

Do you have any questions for me? Feel free to drop me a message. 

References:

1. World Glaucoma Week 2021 | National Health Portal Of India. (n.d.). Www.nhp.gov.in. Retrieved October 11, 2022, from https://www.nhp.gov.in/world-glaucoma-week-2021_pg

2. Glaucoma in Singapore: Stats, Risk Factors and Prevention - HealthXchange. (n.d.). Www.healthxchange.sg. Retrieved October 11, 2022, from https://www.healthxchange.sg/seniors/ageing-concerns/glaucoma-singapore-stats-risk-factors-prevention
3. Azuara-Blanco, A., Burr, J., Ramsay, C., Cooper, D., Foster, P. J., Friedman, D. S., Scotland, G., Javanbakht, M., Cochrane, C., Norrie, J., & EAGLE study group (2016). Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial. Lancet (London, England), 388(10052), 1389–1397. https://doi.org/10.1016/S0140-6736(16)30956-4
4. https://www.healthhub.sg/a-z/diseases-and-conditions/380/glaucoma 

Glaucoma is a disease that can cause vision loss and blindness by damaging the optic nerve, which is located at the back of the eye. This is usually caused by increased eye pressure. Fluid is continuously produced within the eye and if this fluid is unable to drain adequately, it starts to build up and the pressure within the eye increases, leading to damage to the eye nerve and vision loss1.

Eyes with glaucoma have either open angles or closed angles, and I will be focusing on open angle glaucoma in this article as it is the most common subtype of glaucoma worldwide.

As eye pressure usually increases gradually in eyes with open angle glaucoma, most patients do not experience symptoms in the early stages. By the time they discover that some-thing is wrong, the glaucoma is often already very advanced.

By this stage, many are left with no choice but to undergo surgery to prevent the glaucoma from progressing. However, if detected early, glaucoma can be treated with less invasive options such as topical medications and laser procedures.

Please allow me to explain the non-surgical options for treating open angle glaucoma, how
to ascertain whether surgery is necessary and some simple steps you can take to prevent
your glaucoma from progressing.

What are some non-surgical options for treating open angle glaucoma?

For newly diagnosed open angle glaucoma, prescription eye drops are often the first-line treatment. However, recent studies[4] have shown that glaucoma laser procedures are a safe, effective and cost-effective alternative to glaucoma eyedrops as a first-line treatment in newly diagnosed open angle glaucoma patients

Currently, the only modifiable risk factor for glaucoma is eye pressure, hence all glaucoma treatment options aim to reduce the eye pressure. There is no cure for glaucoma and it is not possible to reverse the vision loss or eye nerve damage already sustained.

Hence, it is important to diagnose glaucoma early, initiate treatment as soon as possible, so as to prevent further glaucoma progression.

Type of treatment	How it works	Side effects	Frequency of treatment
Glaucoma Eye Drops	Lowers the pressure in the eye by either reducing fluid production in the eye or increasing the drainage of fluid from the eye.	These may include:   - Stinging, itching, burning in your eye - Blurry vision - Headaches - Changes in the eye colour or the colour of the skin around your eye - Breathing difficulties	Glaucoma eye drops would need to be used everyday as instructed by your eye doctor.
Laser Treatment	Seletive Laser Trabeculoplasty: A laser is used to increase the outflow of fluid from your eye, hence decreasing the eye pressure.	Selective laser trabeculoplasty is generally a very safe procedure which requires only 5-10 minutes. Occasionally, it is associated with these complications, which are often transient: - Increase in eye pressure - Swelling of the cornea, the transparent structure in front of the eye - Swelling of the retina, the light-sensitive tissue at the back of the eye - Eye inflammation	A large study has shown that 3 in 4 patients do not require glaucoma medications 3 years after selective laser trabeculoplasty.   Selective laser trabeculoplasty can be repeated if the eye pressure increases, or other modalities of treatment (eg. glaucoma medications or surgery) may be considered.[1]

When is glaucoma surgery necessary and is surgery always the best option?

While eye drops and laser procedures are usually the first-line treatment options for glaucoma, I would recommend glaucoma surgery in these scenarios:

• If the medicine causes severe and intolerable side effects
• If the patient is unable to adhere to the medication regime and often forgets to use the eye drops, and laser treatment is insufficiently effective in lowering the eye pressure
• The eye pressure is not sufficiently low despite eye drops and/or laser treatment

There are many options for glaucoma surgery in Singapore, and I would tailor the surgery according to each patient’s needs and requirements. Some surgeries I perform are:

Surgery	How it works
Tube implant surgery	A tube is inserted into the eye to allow fluid to drain out.
Trabeculectomy surgery	An incision is made in the eye to allow fluid to drain out.
Minimally Invasive Glaucoma Surgery (MIGS)	MIGS uses microscopic instruments to increase fluid drainage out of the eye. MIGS can be broadly divided into two types:   1. MIGS that increases drainage of fluid via through internal drainage pathways 2. MIGS that drains fluid externally out of the eye area

Please read more about glaucoma surgery here.

Read: Why the Paul Glaucoma Implant is changing the future of glaucoma

What worsens glaucoma and how do you prevent the condition from progressing?

Using your glaucoma eye drops daily as instructed by your eye doctor is crucial in preventing the progression of glaucoma. It is also very important to schedule regular appointments with your eye doctor so that he/she can monitor your eye pressure and glaucoma tests.

While diet and lifestyle have no direct impact on glaucoma, making diet and lifestyle changes can reduce the risk of conditions like diabetes and hypertension which are risk factors for glaucoma.

As such, I recommend:

1. Exercise regularly: This may help to lower eye pressure and keep blood flowing to the nerves in your eye.
2. Eat healthily: Having a nutrient-rich diet can keep your eyes and body healthy.
3. Avoid smoking: Smoking can increase your blood pressure and lead to eye inflammation.
4. Reduce caffeine intake: Too much caffeine can raise your eye pressure.

In conclusion, glaucoma can be treated with surgery as well as non-surgical options. If glaucoma medications and laser procedures work well to reduce your eye pressure, surgery may not be required. If you have any questions regarding glaucoma, please feel free to drop me a message.

References

1. National Eye Institute. (2022, April 21). At a glance: Glaucoma. National Eye Institute. https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/glaucoma
2. Heijl, A., Bengtsson, B., & Oskarsdottir, S. E. (2013). Prevalence and severity of undetected manifest glaucoma: results from the early manifest glaucoma trial screening. Ophthalmology, 120(8), 1541–1545. https://doi.org/10.1016/j.ophtha.2013.01.043
3. National Eye Institute. (2021, July 19). Glaucoma Medicines. National Eye Institute. Retrieved May 5, 2022, from https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/glaucoma/glaucoma-medicines

https://www.thelancet.com/article/S0140-6736(18)32213-X/fulltext

Today, cataract surgery is one of the most commonly performed surgeries in the world. In fact, approximately 10 million¹ procedures are performed globally each year.

Cataract surgery in Singapore is extremely safe with a 98%² success rate. These surgeries enable patients to attain good vision, better than Snellen (internationally-accepted visual requirement for driving) visual acuity of 6/12.

While two decades ago, many cataract surgeries required large incisions and stitches, in recent years, advancements in technology have enabled cataract surgery to be minimally invasive, requiring only a small incision and often no stitches. Minimally invasive cataract surgery, also called phacoemulsification surgery, uses ultrasound energy to break up the cataract into many small pieces which are then suctioned and removed. 

About 10 years ago, femtosecond laser-assisted cataract surgery (FLACS) was developed. At that time, I was working at the ophthalmology department at the National University Hospital, and this was the very first local hospital in Singapore to offer FLACS. Hence, I was privileged to be amongst the first surgeons in Singapore to perform this surgery.  

Since then, many clinics and surgeons have waxed lyrical about FLACS, claiming that it offers increased accuracy and predictability over conventional cataract surgery, and that it has a higher safety profile than conventional phacoemulsification. 

Indeed, is laser surgery truly better than conventional minimally invasive cataract surgery performed with phacoemulsification? Is FLACS suitable for all patients? Let’s find out. 

How is conventional phacoemsulfication cataract surgery or laser cataract surgery performed?

Conventional cataract surgery and FLACS actually share many similarities – for example, both procedures are minimally invasive and usually do not require sutures, and both use ultrasound energy to break up the cataract. The differences between the two procedures are highlighted in red below: 

Conventional phacoemulsification cataract surgery (PCS)

Femtosecond laser-assisted cataract surgery (FLACS)

This conventional surgery uses ultrasound energy to liquify the cataract in the eye. 1. An incision is made in the cornea with the use of a blade. 2. The surgeons manually create a 5-6mm opening in the front of the eye lens capsule. 3. A pen-shaped probe is inserted through the cornea opening to ultrasonically break down and suck up the cloudy lens. 4. An artificial intraocular lens (IOL) is implanted, replacing the natural lens and restoring vision. 5. The incision is self-sealing and usually does not require stitches.

This surgery uses a femtosecond laser to create an opening in the front of the eye lens capsule and fragment the cataract. Just like conventional phacoemulsification surgery, ultrasound energy is then still used to liquify the cataract in the eye,  1. Femtosecond laser makes an incision in the cornea.  2. Femtosecond laser makes an opening in the front of the lens capsule. 3. Femtosecond laser is applied to the cataract to break it into smaller pieces. 4. A pen-shaped probe is inserted through the cornea opening to ultrasonically break down and suck up the cloudy lens. 5. An artificial intraocular lens (IOL) is implanted, replacing the natural lens and restoring vision. 6. The incision is self-sealing and usually does not require stitches. *Energy from the laser helps reduce the amount of ultrasound energy needed to break up the lens prior to removal.

Benefits & disadvantages of laser and traditional cataract surgery

Factor	Conventional phacoemulsification cataract surgery	Femtosecond laser assisted cataract surgery (FLACS)
Precision	No convincing clinical evidence3 to support the claim that FLACS is more precise or effective than conventional phacoemulsification surgery.	No convincing clinical evidence3 to support the claim that FLACS is more precise or effective than conventional phacoemulsification surgery.
Time	More time is required for FLACS compared to conventional phacoemulsification cataract surgery. This is because after laser application in FLACS, phacoemulsification using ultrasound to break up the lens is still required.	More time is required for FLACS compared to conventional phacoemulsification cataract surgery. This is because after laser application in FLACS, phacoemulsification using ultrasound to break up the lens is still required.
Risks	Conventional cataract has a high safety profile. There is a low risk of complications occurring.	In addition to the risks associated with conventional phacoemulsification cataract surgery, FLACS is associated with an additional risk of: - Femtosecond laser-assisted cataract surgery-specific intraoperative capsular complications - Intraoperative miosis
Outcome	Studies4 show that conventional phacoemulsification cataract surgery and FLACS have similar outcomes.	Studies4 show that conventional phacoemulsification cataract surgery and FLACS have similar outcomes.
Recovery time	The recovery time for both types of surgery is similar.	The recovery time for both types of surgery is similar.

To summarize, most studies show that the clinical outcomes of FLACS are similar to conventional phacoemulsification cataract surgery. FLACS does help to reduce the amount of ultrasound energy required to break up the lens prior to removal, but for the vast majority of patients, such levels of ultrasound energy are absolutely safe even without FLACS. While FLACS can make cornea incisions to reduce astigmatism, the outcome may not be predictable or long-lasting, hence I prefer toric intraocular lenses to FLACS for astigmatism correction. 

Importantly, FLACS is expensive and not cost-effective for the vast majority of patients, who can achieve similarly excellent outcomes from conventional ultrasound cataract surgery alone. 

Which one is more suitable for me?

My opinion is that FLACS is an unnecessary and expensive procedure for the vast majority of patients, hence I would usually recommend conventional ultrasound cataract surgery alone. However, in a minority of patients who have a low baseline cornea endothelial cell count (eg. Fuch’s endothelial dystrophy), I would suggest that they consider FLACS to reduce the amount of ultrasound energy required to break up the cataract. 

When should I have cataract surgery?

Many patients wrongly believe that they should wait till their cataracts are extremely advanced and their vision becomes exceedingly poor before they should undergo cataract surgery. This belief stems from a time when cataract surgery was performed with large incisions and was associated with poorer outcomes and more complications. 

Today, minimally invasive cataract surgery performed with small incisions is associated with excellent outcomes and a high safety profile. Hence, you can choose to undergo cataract surgery once the cataract is affecting your vision and compromising your quality of life. Unnecessarily delaying cataract surgery would not only increase the complexity and risk of the surgery, but is also associated with a higher risk of falls and fractures⁵. 

Choosing the right surgeon for your cataract surgery

Ultimately, it is important that you choose a surgeon that you can trust and who can address your concerns. And when it comes to surgeons, here are a few non-negotiables:

• Your surgeon must be an experienced and qualified cataract surgeon.
• Your surgeon should be accredited in both conventional phacoemulsification cataract surgery as well as FLACS, so that he/she can objectively assess which option is more suitable for you. 
• He/she should be someone that you can trust to have your best interests at heart. 
• He/she should be willing to spend the time to explain the treatment options in detail, so that you can make an informed decision.

To find out more about cataract surgery in Singapore, please read my guide on cataracts, and contact me if you have any questions! 

References:

1. FOSTER ACataract and “Vision 2020—the right to sight” initiativeBritish Journal of Ophthalmology 2001;85:635-637.
2. https://www.singhealth.com.sg/patient-care/patient-education/clinical-outcomes-snec#:~:text=Cataract%20Surgery&text=Cataract%20surgeries%20performed%20by%20consultants,requirement%20for%20driving)%20or%20better.
3. Roberts, H. W., Day, A. C., & O'Brart, D. P. (2020). Femtosecond laser-assisted cataract surgery: A review. European journal of ophthalmology, 30(3), 417–429. https://doi.org/10.1177/1120672119893291 
4. Levitz, L., Reich, J., & Hodge, C. (2018). Posterior capsular complication rates with femtosecond laser-assisted cataract surgery: a consecutive comparative cohort and literature review. Clinical ophthalmology (Auckland, N.Z.), 12, 1701–1706. https://doi.org/10.2147/OPTH.S173089
5. https://bjo.bmj.com/content/89/1/53 

Undergoing glaucoma surgery in Singapore can be a daunting process, but thanks to new advances in ophthalmology medicine and technology, it isn’t as intimidating anymore – including the recovery process.

Can you lead a normal life after glaucoma surgery? Will surgery improve your vision? Will your eye pressure go back up?

For this article, I will talk about the three most commonly performed types of glaucoma surgeries - trabeculectomy, tube implant surgery, and minimally invasive glaucoma surgery (MIGS).

How is glaucoma surgery done in Singapore?

If glaucoma laser treatment and medications haven’t lowered your eye pressure sufficiently, or if you’re experiencing side effects from the medications, your doctor may recommend surgery instead¹.

There are a few types of glaucoma surgeries that can lower the pressure in your eyes, including:

Type of surgery	How it works	What does it treats
Trabeculectomy	The surgeon creates a tiny opening in the top part of your eye, under your eyelid. The opening enables fluid in your eye to drain away, reducing the eye pressure.	Open angle glaucoma Angle closure glaucoma
Tube implant surgery	The surgeon implants a tube into your eye. The tube helps to drain excess fluid from your eye. There are a few types of tube implants. I am part of a team which helped to develop the Paul Glaucoma Implant (PGI), a novel tube implant. Study results suggest that the PGI is associated with a lower rate of complications compared with previous tube implants, with higher efficacy compared with some of the previous tube implants.	Open angle glaucoma Angle closure glaucoma Congenital glaucoma Secondary glaucoma, including uveitic glaucoma, traumatic glaucoma and neovascular glaucoma
Minimally invasive glaucoma surgery (MIGS)	Microscopic implants are inserted into the eye with small incisions. The safety profile of MIGS is higher compared with conventional glaucoma surgery, and it effectively lowers the eye pressure in appropriately selected glaucoma patients.	Mild to moderate glaucoma

It is important to note that there is no cure for glaucoma – even with surgery. The damage inflicted on the eye nerve by glaucoma is irreversible. Glaucoma surgery aims to lower eye pressure and prevent further vision loss².

Do and don’ts after glaucoma surgery in Singapore

Type of surgery	Post-operation protocol	Side effects and period
Trabeculectomy	1. Wear an eye shield when sleeping for up to 3-4 weeks after surgery. 2. Do not rub or press on your eye after surgery, to avoid infection or injury to the eye. 3. Use antibiotic and steroid eye drops as prescribed by your doctor after the surgery. Antibiotic eyedrops are generally required for about a month. Steroid eyedrops are to be instilled 6-8 times a day initially, and the frequency will be gradually reduced. Steroid eyedrops may be required for several months after surgery. 4. Do not bend over and avoid strenuous activities such as weightlifting until your doctor says that it is safe to do so. 5. Do not use eye make-up for at least 3 weeks after surgery. 6. Avoid contact lens wear until your doctor says that it is safe to do so. 7. Do not swim for at least a month. Swimming can cause serious infections after surgery. Some patients who have undergone trabeculectomy would need to avoid swimming permanently,	Discomfort and blurry vision may last for up to a few weeks after the surgery.  Some patients experience permanent eye discomfort or dryness after trabeculectomy, and they may also have a life-long risk of sight-threatening eye infection.
Tube implant surgery	Same as Trabeculectomy, except it is unlikely that patients with tube implants would need to avoid swimming permanently	Discomfort and blurry vision may last for up to a few weeks after the surgery.  Permanent eye discomfort or dryness after tube implant surgery is unlikely. Patients with tube implants also usually do not have a life-long risk of sight-threatening infection.
MIGS	Same as trabeculectomy, except a shorter duration of steroid eyedrops is required (often just 1-2 months). It is also unlikely that patients who have undergone MIGS would need to avoid swimming permanently.	Compared to trabeculectomy and tube implant surgery, MIGS is a lot less invasive, hence recovery is a lot faster, often with good vision within a week.   Permanent eye discomfort or dryness after MIGS is unlikely. Patients with MIGS also usually do not have a life-long risk of sight-threatening infection.

Can I lead a normal life after glaucoma surgery in Singapore?

Ultimately, the aim of glaucoma surgery is to preserve your vision by lowering your eye pressure.  MIGS patients often experience a fast recovery and most patients can return to normal activities soon after surgery. Patients with tube implants also often resume their normal activities 1-2 months after surgery, and usually do not need to make long-term changes to their lifestyle.

Unfortunately, many trabeculectomy patients are unable to swim for life, as they have a life-long risk of sight-threatening infection. With that said, recovery and quality of life after surgery vary amongst patients depending on how you respond to the surgery.

It is important to note that surgery is unable to reverse your vision loss from glaucoma – regardless of the type of surgery.

Surgery aims to prevent further vision loss and further damage to the eye nerve. This allows you to continue to be independent in your daily activities. Depending on the severity of your glaucoma, you may still require glaucoma medications after surgery. However, glaucoma surgery also often reduces the number of glaucoma medications required, hence improving your quality of life by reducing the side effects from these medications³.

To achieve the best outcomes after glaucoma surgery, I emphasize the importance of using the post-operative eyedrops as prescribed, and the need for regular review after surgery so that your doctor can monitor the eye pressure and alter the medications accordingly.

What are the risks of glaucoma surgery?

As with all surgeries, glaucoma surgery are associated with some risks. To date, Minimally Invasive Glaucoma Surgery (MIGS) has the highest⁴ safety profile.

Type of surgery	Associated Risks
Trabeculectomy	- Loss of vision - Cataract - Sight-threatening eye infection (risk can be life-long) - Bleeding in the eye - Droopy eyelids - Persistent eye discomfort - Eye pressure that is too low - Failure of surgery with raised eye pressure and glaucoma progression
Glaucoma implant surgery	- Loss of vision - Cataract Infection (unlikely to have life-long risk) - Bleeding in the eye. - Droopy eyelids (risk lower than trabeculectomy) - Eye pressure that is too low - Failure of surgery with raised eye pressure and glaucoma progression
Minimally invasive glaucoma surgery (MIGS)	- Infection (unlikely to have life-long risk) - Bleeding in the eye - Droopy eyelids (risk lower than trabeculectomy) - Failure of surgery with raised eye pressure and glaucoma progression

What are the success rates for glaucoma surgery in Singapore?

Trabeculectomy

• Complete success rates of 36-65% after 5 years depending on the definition of success[6][1]
  • 65% — ≤ 21 mmHg target eye pressure 
  • 55-60% — ≤17 mm Hg target eye pressure
  • 35-45% — ≤15 mm Hg target eye pressure

• Risk factors for trabeculectomy failure include pigmented races, the use of multiple glaucoma eyedrops and previous eye surgery

Tube implant surgery

• Success rates are higher than trabeculectomy in patients with previous incisional surgery[7]
• While the Baerveldt Glaucoma Implant (BGI) has a higher success rate compared to the Ahmed Glaucoma Valve (AGV), it is associated with a significantly higher risk of hypotony (eye pressure being too low) [8]. Early studies show that the Paul Glaucoma Implant (PGI) has a 93.2%[9] success rate  — similar efficacy to the Baerveldt but with a lower risk of complications.

MIGS

• Success rate is dependent on the type of procedure carried out
• Patients with mild to moderate glaucoma on 1-2 glaucoma medications can achieve at least 20% eye pressure reduction without the need for medication for 24 months [10]
• However, long term outcomes of MIGS have yet to be ascertained

Regardless of the type of glaucoma surgery performed, regular eye examinations are vital to monitor your eye pressure and glaucoma.

While glaucoma surgery cannot cure glaucoma, it is often successful in reducing your eye pressure and preventing vision loss. Early detection and treatment of glaucoma can preserve your vision, hence I would encourage everyone to go for regular eye screenings as early glaucoma often has no symptoms.

If you have any questions regarding glaucoma or need a second opinion for your diagnosis, please feel free to drop me a message and I am more than happy to help.

References

What do That 70s Show starlet Mila Kunis, talk show magnate Larry King and local songwriter Dick Lee have in common? Apart from being rich and famous, they’ve all had cataract surgery. 

For us in Singapore, cataracts might seem like part and parcel of ageing – in Singapore, cataract affects¹:

• 78.6% of the elderly
• 63.6% of people aged 60 to 64
• 94.6% of people aged 75 and older 

But did you know that this condition can also affect younger people? We refer to this as early-onset cataracts.

Understanding early-onset cataracts

A cataract is the clouding of a normally clear lens. For those with cataracts, seeing is like looking through a foggy window. Clouded vision caused by cataracts can make it more difficult to read, drive a car (especially when it’s dark), or see the expressions of our loved ones.

There are three common types of cataracts, named for where they are located in relation to the lens:

• Nuclear cataract: Develops in the nucleus, or centre of the lens.
• Cortical cataract: Develops on the outside, or cortex of the lens.
• Posterior subcapsular cataract: Develops in the backmost layer of the cortex, on the lens capsule.

Nuclear and cortical cataracts tend to develop slowly, and usually become more problematic with age. Unlike nuclear and cortical cataracts, posterior subcapsular cataracts are frequently found in younger individuals and can progress more quickly.

Why cataracts develop in young people

There is a perception that cataracts only affect elderly persons; However, young persons, even those in their 20s, can develop cataracts.  

Certain conditions and risk factors can result in the development of cataracts at a younger age. 

These include:

Diabetes 

• In diabetic individuals with poorly controlled blood sugar levels, enzymes convert the high levels of glucose into sorbital, which affect the lens clarity and result in cataracts.
• The risk of cataracts is doubled in diabetics². 
• Singaporeans are becoming diabetic at a younger age. NUS research studies³ have found that 34% of Singaporeans aged 24 to 35 will develop diabetes by age 65. This may result in more Singaporeans developing cataracts at a younger age.

Trauma

• Both blunt and penetrating trauma disrupt lens fibres and result in cataracts.
• Penetrating eye injury may puncture the lens capsule and induce a cataract.
• Blunt eye injury can cause a diffuse cataract with a higher risk of zonular loss, which results in the lens being shaky or unstable. Cataract surgery is much more complex and is associated with higher risks in such cataracts.
• Typically, trauma-related cataracts can progress rapidly. 

Radiation 

• Exposure to high levels of radiation can result in cloudy vision in less than two years
• Exposure can also take over a decade to affect one’s vision.

Drug exposure and reaction

• It’s believed that the chronic use of drugs such as statins and steroids⁴ can contribute to early cataract formation.

Other common risk factors for early cataracts include; 

• Obesity
• Previous eye surgery (eg. retina or glaucoma surgery)
• A family history of early-onset cataracts
• Congenital medical conditions
• Poor nutrition 
• Smoking 
• Excessive alcohol consumption

Many of these factors can be effectively managed. If you want to avoid having cataracts at a young age, focus on maintaining a healthy lifestyle.

What do early cataracts look like? 

In its initial stages, a cataract may only affect a small part of the eye lens, and individuals may be unaware of any vision loss. As cataracts become more advanced, they increasingly impede the passage of light that passes through your lens. This will lead to more symptoms.

Some symptoms of cataracts include:

• Cloudy, blurred or dim vision
• Increasingly poor night vision
• Sensitivity to bright light and glare
• Needing brighter light for reading and other activities
• Frequent changes in your eyeglass or contact lens prescription
• Seeing halos around lights
• Colours appear faded or have a yellowish tinge
• Double vision in one eye

Can children have cataracts?

A child may have a congenital cataract, or they may develop the condition later in life. The following may cause cataracts in children:

• Poisoning
• Steroid use
• Eye injury or trauma
• Inflammation in the eye
• Medical conditions (eg. diabetes, rheumatoid arthritis)
• Complications from other eye diseases (eg. glaucoma)
• Down syndrome

Are childhood cataracts the same as congenital cataracts? 

The short answer is no. A cataract may develop during childhood due to the conditions listed above, but if the cataract is already present at birth, it is a congenital cataract. 

A congenital cataract is a rare birth defect that can cause vision problems or even blindness. A baby may have a cataract in one or both eyes. The most common infections that cause congenital cataracts include toxoplasmosis, rubella, cytomegalovirus and herpes simplex virus.

At what stage should cataracts be removed? 

While most age-related cataracts progress gradually over years, early-onset cataracts may develop rapidly in a short period of time, especially in high-risk individuals.

This is why no matter your age, you should take an eye exam the moment you notice any changes in your vision. Symptoms such as sudden vision changes, seeing flashes of light, and sudden eye pain might all be cause for immediate concern.

There is no medication or eye drop that can treat cataracts. Removing them with surgery is the only way to treat and stop cataracts from progressing. 

But the most important thing to remember is: The earlier visually-significant cataracts are detected, the earlier they can be treated.Patients who wait more than 6 months⁵ for cataract surgery have been known to experience vision loss, reduced quality of life, and an increased rate of falls.

To find out more about cataract surgery in Singapore, please read my cataracts guide, or feel free to drop me a message. 

References

1. Cataract - NUH | National University Hospital. (n.d.). Www.nuh.com.sg. Retrieved April 7, 2022, from https://www.nuh.com.sg/About-NUH/Clinical-Outcomes/Pages/Cataract.aspx#:~:text=In%20Singapore%2C%20the%20percentage%20of
2. Becker, C., Schneider, C., Aballéa, S., Bailey, C., Bourne, R., Jick, S., & Meier, C. (2018). Cataract in patients with diabetes mellitus—incidence rates in the UK and risk factors. Eye, 32(6), 1028–1035. https://doi.org/10.1038/s41433-017-0003-1
3. https://sph.nus.edu.sg/2016/05/young-singaporean-diabetes-on-the-rise/#:~:text=Diabetes%20in%20Singapore%20is%20on,by%20the%20age%20of%2065. 
4. Wise, S. J., Nathoo, N. A., Etminan, M., Mikelberg, F. S., & Mancini, G. B. J. (2014). Statin Use and Risk for Cataract: A Nested Case-Control Study of 2 Populations in Canada and the United States. Canadian Journal of Cardiology, 30(12), 1613–1619. https://doi.org/10.1016/j.cjca.2014.08.020
5. Hodge, W., Horsley, T., Albiani, D., Baryla, J., Belliveau, M., Buhrmann, R., O’Connor, M., Blair, J., & Lowcock, E. (2007). The consequences of waiting for cataract surgery: a systematic review. Canadian Medical Association Journal, 176(9), 1285–1290. https://doi.org/10.1503/cmaj.060962

Cataracts. This prevalent eye condition is the leading cause of blindness worldwide and is also known to be one of the top global causes of visual impairment. Today, cataracts affect more than 95 million people globally, and remains the top cause of blindness in developing nations.

Individuals with visually significant cataracts tend to experience symptoms including blurred vision, loss of contrast and colour, halos and glare. These symptoms can heavily impact patients’ day-to-day lives, and this is made even more apparent via studies that have linked increased mortality in older persons with cataracts.

Thankfully, vision loss from cataracts can be effectively restored with modern surgical options today. Cataract surgery is considered to be one of the most cost-effective interventions available in modern health care and is known to consistently improve patients’ quality of life.

Many patients get used to the visual impairment associated with cataracts, hence may not notice any functional decline. Educating the Singaporean public regarding the prevalence, risk factors and treatment options for cataracts will increase the awareness of eye health. 

Ready? Here we go:

An introduction to cataracts

Cataract is the leading cause of blindness affecting millions of people globally, with individuals aged 40¹ and above at an increased risk of developing this condition.

Here in Singapore, studies have shown that about 95% of the population above 70 years of age, and 80% of those aged 60 and above, have cataracts. For Singaporeans aged 45 and above, 30% had cataracts.

It wouldn’t be surprising to have a parent or older relative who has cataracts. What is surprising, however, is that the number of cataract cases may actually be even higher – a study by the Singapore Epidemiology of Eye Diseases programme found that nearly 70%² of Singaporean adults who are over the age of 40 and have visually significant cataracts were obliviously unaware of their condition.

This lack of awareness means that many patients are unnecessarily suffering from poor eyesight when a quick and safe procedure can restore their vision. If you are reading this cataract guide, you have come to the right place to find out everything you need to know about this easily-treatable condition.

What is a cataract?

A cataract develops when the natural lens in our eyes becomes cloudy or opaque. This cloudiness is usually caused by aggregated protein, which results in blurring of vision. Even an early cataract can affect one’s colour perception and contrast sensitivity.

A cataract is not just a concern for those in their old age; they can also appear as a result of eye injuries, or following eye surgery for other conditions. They can also be present from birth. In some developing nations, where healthcare and medical services may be less readily available, cataracts are a leading cause of blindness.

Certain conditions are associated with early cataracts. These include high myopia, diabetes, prolonged steroid use, eye trauma, and smoking.

The three main types of cataracts

Nuclear cataract	Posterior sub-capsular	Cortical cataract
This cataract is most commonly associated with old age. The cloudiness occurs in the centre of the lens.	The cloudiness occurs in the cortex or peripheral part of the lens, progressing towards the centre like spokes on a wheel.	An opaque area forms at the back of the lens. This usually occurs in long-term steroid users.

Cataracts: The facts and figures in Singapore

Despite being easily treatable, cataract continues to be the leading cause of visual impairment amongst elderly adults in Singapore³ and other developed countries - Additionally, as our population continues to age, the number of people experiencing vision loss as a result of cataract will only increase⁴. 

In Singapore, 78.6% of the elderly are affected by cataracts. And it appears that the number of people affected by cataracts only increases with age - The condition affects 63.6% of people between the ages of 60 to 64, and a whopping 94.6% of individuals aged 75 and above.

What are the risk factors of cataracts?

A cataract is largely an age-related condition, which is why individuals over the age of 40 should pay increased attention to their vision and go for routine eye check-ups. Apart from ageing, cataracts are also associated with:

• Eye trauma or inflammation
• Previous eye surgery (eg. refractive surgery)
• High degree of myopia
• UV radiation exposure
• Ionising radiation exposure (eg. x-rays and gamma rays)
• Prolonged use of steroid medication (eg. oral steroids, nasal sprays, eyedrops etc.)
• Obesity⁵
• Smoking⁶
• Alcohol consumption
• Uncontrolled diabetes⁷
• Congenital cataract

What are some of the common symptoms of cataracts?

Usually, cataract patients do not experience itching, tearing or any headaches. Rather, common cataract symptoms include:

• Blurred or dim vision
• Difficulty seeing in low light conditions
• Sensitivity to light (lights might look glaring)
• Seeing a halo around bright lights
• Colours looking faded or muted
• Your vision looking washed-out

If you have cataracts, things might start to look dim or blurred, almost like you’re looking through a fog. As the cataract worsens, one’s vision will slowly become cloudier, eventually making it hard to even make out details or colours. If left untreated for too long, cataracts can sometimes result in glaucoma or even blindness, hence it is essential that you visit a trusted eye doctor if you experience these symptoms.

If you’re still unsure about how cataracts affect your vision, try this online simulator to see the world from the eyes of a person with cataracts.

What is a cataract check-up like?

A screening or check-up for cataracts will typically involve various tests, including:

• Checking your vision
• Manifest Refraction, which involves the manual measurement of your prescriptive power by placing lenses of varying degrees in front of your eyes
• An eye pressure test, which will give an indication of whether you are at risk of glaucoma.

The actual test to confirm if there are cataracts in your eye involves instilling eye drops to dilate the pupil of your eye. Once your pupils are dilated, your eye doctor will use a Slit Lamp to look for signs of cataracts and other conditions. A photograph will be taken to document the appearance of your cataract.

After your tests, you will have a consultation with your doctor, who will explain the examination findings, answer your questions, and openly discuss your condition and the treatment options available.

What are the different treatment options available for cataracts?

The only known effective way to treat cataracts is to surgically remove them. Thankfully, modern cataract surgery is a highly effective way of restoring vision to individuals who have become visually impaired due to cataracts.

What are the procedures for cataract surgery like?

The oldest surgical methods for removing cataracts date back to archaic techniques such as ‘couching⁸’ and ‘needling’, which are honestly best left un-googled as they look brutal. Thankfully, cataract surgery today is much less terrifying and way more effective, with excellent outcomes:

Micro-incision phacoemulsification surgery

Laser-assisted cataract surgery

Intraocular Lens (IOL)

An intraocular lens implant is an artificial replacement for the lens of your eye, and a crucial part of the surgery process. 

Once cataracts and the natural lens have been removed, an artificial intraocular lens (IOL) is implanted through a small 2-3mm incision.

The implantation of the IOL is a permanent procedure, so the lens need not be replaced. 

An IOL is made of clear acrylic and comprises several different types⁹.

Lens type	Pros	Cons
Monofocal IOL	This common IOL provides good vision at a specific distance. Toric monofocal IOLs also correct for astigmatism.  Monovision: Provides good distance vision in one eye, and good close-up vision in the other This will allow most patients to be spectacle-independent.	You might be able to see distant things perfectly well but will likely need glasses to see close up or read. For patients who choose monovision, you may not get used to using one eye for distance vision and one eye for near vision. This may also compromise your depth perception.
Multifocal IOLs	Provides good vision, both near and far, without glasses. This is suitable for patients who: Want to reduce spectacle use Have minimal astigmatism Mostly drive in the day These lenses should be used in both eyes for the most optimal results.	After surgery, some people may notice: Difficulty reading small print in dim light Dimmer vision Seeing halos around lights and experience glare at night Most patients get used to these symptoms and are not bothered by them. However, monofocal IOLs still provide better quality of vision if one does not mind wearing spectacles for near vision.
Extended Depth of Focus IOLs	Provides good distance and intermediate vision without the need for glasses. This type of lens is suitable for those who: Want to rely on their glasses less for distant and intermediate distance vision (eg. using the computer) Do not mind wearing glasses for near vision Drive at night and in the day	Near vision is limited for patients with Extended Depth of Focus IOLs. After surgery, some people may: Require glasses for reading small print up close Seeing halos around lights and experience glare at night, though at a lesser extent compared with Multifocal IOLs

Your choice of lenses depends on the health of your eye, your lifestyle, and your preferences. Discuss your IOL options with your doctor in detail before making your choice.

Can I operate on both eyes on the same day?

Due to very rare potential complications such as bilateral-eye infections, doctors usually recommend a separate surgery date for each eye. This is certainly the safer option, though for very rare circumstances, eg. a patient who requires general anaesthesia for cataract surgery for whom the risks of anaesthesia is high, rarely bilateral cataract surgery on the same day may be considered.

What should one expect cataract surgery to be like?

While it depends on the complexity of your condition, most cataract surgeries take 10-20 minutes. This is a day surgery procedure, so you can go home on the same day.

Before surgery, most adult patients are given local anaesthetic and/or sedatives. Children undergoing cataract surgery, on the other hand, usually require general anaesthetic.

Here’s what you need to know about preparing for cataract surgery:

What happens during cataract surgery?

To help you relax or to fall asleep, an anaesthetist will sedate you intravenously. Your doctor will assess whether you are suitable for sedation during surgery.

Your surgeon will use anaesthetic eye drops to numb your eye so you will not feel any pain during the surgery, though you might experience a sensation of pressure on your eye.

How soon can I resume normal activities post-surgery?

After the procedure, a plastic shield will be placed over the operated eye to protect it for a day or two. Most patients can usually go home on the same day.

You will be given medical leave that may last up to 4 weeks.

Although it can take a month for the eye to fully recover, most patients are able to return to work the week after their surgery. If your work involves being in a dusty or smoky environment, it is recommended to stay away from work for a longer time. 

Post-operative reviews are typically scheduled at 1 day, 1 week, and 1 month after surgery.

What are some of the possible side effects or risks of treatment?

Cataract surgery is a low-risk procedure with a very high success rate. However, all surgeries have potential complications. Infections after cataract surgery occur in 1 out of every 1,000 cases, and can result in blindness. The following are some other rare complications that may arise from surgery:

• A detached retina: This is a medical emergency that occurs if a crucial layer of nerve cells separates from the back of your eye. Another surgery is required to address the detached retina.
• Posterior capsular rupture: This occurs when the capsule around the cataract breaks during surgery and fragments of the cataract can fall into the back of a patient’s eye. Follow-up surgery might be required. 
• High eye pressure: The eye pressure can be raised after cataract surgery, and this is usually transient.
• Residual refractive errors after cataract surgery: Spectacles may be required if this happens. LASIK can also correct such refractive errors.
• Dislocation or malposition of the implant.
• Damage of the cornea, which is the transparent structure in the front of the eye. 
• Posterior capsular opacification (after-cataract):While cataracts do not return, cloudiness may be noticeable by patients months or years after the surgery. This cloudy layer is scar tissue forming behind the lens implant. YAG laser capsulotomy surgery can be performed to correct the problem, especially if your vision is impacted.

Apart from the risks listed above, the more common side effects encountered after cataract surgery are dry eye and night vision problems. And while these side effects are usually temporary, they may last up to 6 months. 

After going through surgery, it is important to closely monitor your condition. If you experience any increased redness, eyelid swelling, eye pain, eye discharge or blurring of vision, please make an appointment with your doctor immediately.

Is there any way to avoid developing cataracts?

Cataracts usually do not develop rapidly. In fact, it might take up to several years before a cataract gets to the point where it starts to affect a person’s daily life. The progression might be slow, but it is not reversible without surgery.

How to prevent cataracts?

• Wear sunglasses and wide-brimmed hats to protect your eyes when under the sun.
• See your eye doctor regularly: Early detection helps you to optimize your vision despite early cataracts.  
• Eat well: A balanced diet comprising leafy vegetables, whole grains, nuts, citrus fruits, and fish that are rich in omega-3 fatty acids will go a long way in preventing cataracts. 
• Keep your diabetes under control
• Drink alcohol in moderation and stop smoking

Who should get tested for cataracts?

You should make it a point to go for regular eye check-ups once you hit the age of 40. Besides cataracts, there are other conditions that may affect your vision, such as retinal tears, macular degeneration, floaters, glaucoma, refractive errors, and more. With our eyes being potentially susceptible to a wide range of eye diseases, it is advisable to have regular full eye check-ups¹⁰ instead of just checking for the presence of cataracts. 

If you have any eye conditions in addition to cataracts, you may be eligible for cataract-plus procedures which offer additional benefit to cataract surgery alone. For example, glaucoma patients undergoing cataract surgery may choose to simultaneously undergo glaucoma surgery that’ll improve their eye pressure and lower their need for glaucoma medication.

Such procedures may be more common than you think, as about 10% of Singaporeans aged 70 and above have glaucoma, according to CNA Lifestyle.

When should one have cataract surgery?

Many people think that in order to successfully remove a cataract, you have to wait till the cataract gets ‘ripe’ or ‘mature’ before going for surgery. This belief is bogus today - it stemmed from the time when cataract surgery had significant risks hence was only advised for advanced cataracts. 

The vast improvements in cataract surgery and the high safety profile of the procedure means that surgery can be offered for cataracts at any stage of development. There is really no need to wait until your cataract ‘ripens’ and becomes advanced as it may increase the risks and complexities of the surgery.

If your cataracts are impairing your vision and interfering with your daily life, it’s time to see a trusted doctor. If your cataract is in its early stages and does not interfere with your daily activities, you may choose to delay having surgery. 

Moreover, as cataracts tend to affect your spectacles prescription, you’ll need to have your vision checked yearly and get a new pair of spectacles if need be.

Which surgeon or eye clinic should you choose?

When it comes to assessing the myriad of options available for potential cataract surgery, saving money and going cheap should not be prioritised above the credibility and reputation of your eye doctor or clinic.

You would do well to check and read through reviews online. Don’t forget to ask trusted friends and family for recommendations.

Also, your eye doctor should be able to listen to your needs, answer your questions, allay your fears, and eventually give you an unbiased consultation. Importantly, you should find a doctor who makes you feel comfortable and reassured.

Conclusion

Individuals with visual impairment are known to have lower self-esteem compared to their sighted peers¹¹. Further research states that for individuals with cataracts or other causes of visual impairment, healthy self-esteem is impacted by quality social support, independence in conducting their daily activities, patients’ perceived independence, and more¹².

Simply put, losing your vision is a slippery slope that you do not want to go down. Do not tarry, and keep your eye on the ball.

References

1. Liu, Y. C., Wilkins, M., Kim, T., Malyugin, B., & Mehta, J. S. (2017). Cataracts. Lancet (London, England), 390(10094), 600–612. https://doi.org/10.1016/S0140-6736(17)30544-5
2. Chua, J., Lim, B., Fenwick, E. K., Gan, A. T., Tan, A. G., Lamoureux, E., Mitchell, P., Wang, J. J., Wong, T. Y., & Cheng, C. Y. (2017). Prevalence, Risk Factors, and Impact of Undiagnosed Visually Significant Cataract: The Singapore Epidemiology of Eye Diseases Study. PloS one, 12(1), e0170804. https://doi.org/10.1371/journal.pone.0170804
3. Sabanayagam, C., Fenwick, E., Ong, P. G., Tey, M. L., Tapp, R., Cheng, C. Y., Cheung, G. C., Aung, T., Wong, T. Y., & Lamoureux, E. (2016). Visual Impairment in Old and Very Old Community-dwelling Asian Adults. Ophthalmology, 123(11), 2436–2438. https://doi.org/10.1016/j.ophtha.2016.06.036
4. Wong T. Y. (2001). Cataract extraction rates among Chinese, Malays, and Indians in Singapore: a population-based analysis. Archives of ophthalmology (Chicago, Ill. : 1960), 119(5), 727–732. https://doi.org/10.1001/archopht.119.5.727
5. Pan, C. W., & Lin, Y. (2014). Overweight, obesity, and age-related cataract: a meta-analysis. Optometry and vision science : official publication of the American Academy of Optometry, 91(5), 478–483. https://doi.org/10.1097/OPX.0000000000000243
6. Ye, J., He, J., Wang, C., Wu, H., Shi, X., Zhang, H., Xie, J., & Lee, S. Y. (2012). Smoking and risk of age-related cataract: a meta-analysis. Investigative ophthalmology & visual science, 53(7), 3885–3895. https://doi.org/10.1167/iovs.12-9820
7. Tan, A. G., Kifley, A., Tham, Y. C., Shi, Y., Chee, M. L., Sabanayagam, C., Tan, N., Wong, K. H., Mitchell, P., Cumming, R. G., Wong, T. Y., Wang, J. J., & Cheng, C. Y. (2018). Six-Year Incidence of and Risk Factors for Cataract Surgery in a Multi-ethnic Asian Population: The Singapore Epidemiology of Eye Diseases Study. Ophthalmology, 125(12), 1844–1853. https://doi.org/10.1016/j.ophtha.2018.07.026
8. Ademola-Popoola, D. S., & Owoeye, J. F. (2004). Traditional couching for cataract treatment: a cause of visual impairment. West African journal of medicine, 23(3), 208–210. https://doi.org/10.4314/wajm.v23i3.28122
9. https://www.singhealth.com.sg/patient-care/patient-education/cataracts
10. Chua, J., Lim, B., Fenwick, E. K., Gan, A. T., Tan, A. G., Lamoureux, E., Mitchell, P., Wang, J. J., Wong, T. Y., & Cheng, C. Y. (2017). Prevalence, Risk Factors, and Impact of Undiagnosed Visually Significant Cataract: The Singapore Epidemiology of Eye Diseases Study. PloS one, 12(1), e0170804. https://doi.org/10.1371/journal.pone.0170804
11. Papadopoulos, K., Montgomery, A. J., & Chronopoulou, E. (2013). The impact of visual impairments in self-esteem and locus of control. Research in developmental disabilities, 34(12), 4565–4570. https://doi.org/10.1016/j.ridd.2013.09.036
12. Papadopoulos K. (2014). The impact of individual characteristics in self-esteem and locus of control of young adults with visual impairments. Research in developmental disabilities, 35(3), 671–675. https://doi.org/10.1016/j.ridd.2013.12.009 

Glaucoma is the leading cause of blindness in the world. It is an irreversible chronic disease that affects children and adults; globally, the number of glaucoma patients is expected to increase by 74% by 2040¹. 

In Singapore, nearly 10% of people over the age of 70 have glaucoma². Considering how glaucoma is largely symptom-free and is hence touted as the “silent thief of sight”, I believe that we still have many unreported cases amongst us. 

Unfortunately, many people are still losing vision from glaucoma. 

The current mainstay for glaucoma treatment includes eye drops, the success of which highly depends on patient compliance. Furthermore, the patient must adhere to this treatment for life. 

If glaucoma eye drops do not lower the eye pressure sufficiently, or if the patient is unable to use the eye drops regularly, conventional glaucoma surgery including trabeculectomy is an option. Trabeculectomy is effective in lowering eye pressure but may be associated with blinding complications including a life-long risk of infection. 

Another lesser-known surgical alternative is glaucoma tube implants, which have been used to treat severe glaucoma in the past 30 years with much success. However, until recently, the options for tube implants were limited and the commonly used tube implants were invented more than 20 years ago. 

It is time that we take advantage of the advanced technological advancements to develop newer, more effective and safer tube implants for the benefit of our glaucoma patients. 

In 2012, my colleague Professor Paul Chew and I, together with a team of clinician-scientists from the National University Health System, started developing a new tube implant – the Paul Glaucoma Implant (PGI). The goal was to create an implant that is better than currently available devices — and we sure did. 

Today, the PGI is used in 17 countries worldwide and has greatly improved many patients’ quality of life. Read all about it in this Straits Times feature. 

In this article, allow me to explain what glaucoma tube implants are, how the Paul Glaucoma Implant fares against current choices and why I believe this new invention will greatly change the treatment landscape for glaucoma. 

What are glaucoma tube implants? 

With glaucoma, the fluid within the eye does not drain properly. This results in elevated eye pressure (or intraocular pressure) which damages the eye nerve, eventually leading to blindness if untreated. 

Hence, the only effective way to treat glaucoma is to reduce eye pressure. 

Glaucoma tube implants are devices placed in the eye to allow fluid to drain out of the eye. This helps lower eye pressure and prevents further damage to the eye nerve. 

There are a few types of glaucoma implants out there, but regardless of which implant is used, it should be noted that the implants do not improve vision. Instead, they are used to lower eye pressure and prevent further vision loss from glaucoma. 

When are glaucoma tube implants used?

Glaucoma tube implants are typically used in situations such as: 

• Severe and complicated glaucoma 
• Injuries to the eye 
• Childhood glaucoma 
• Neovascular glaucoma 
• If non-surgical alternatives and other surgeries have not worked 

Current types of glaucoma tube implants in Singapore

All tube implants have a smaller tub attached to a larger plate. 

There are two types of glaucoma implants — valved and non-valved. Respectively, the two most commonly used tube implants are the Ahmed Glaucoma Valve (AGV) and the Baerveldt Glaucoma Implant (BGI). The Baerveldt implant has a larger plate compared with the Ahmed implant (350mm2 vs 184mm2). 

The option you choose depends on a few factors, including the severity of your condition and whether you’ve had surgical interventions in the past. 

In terms of results and efficacy, comparison studies³ have found that the Baerveldt has a lower failure rate but significantly higher risk⁴ of hypotony (low eye pressure). The superior efficacy of the Baerveldt implant is thought to be related to its larger plate size. While the valve mechanism of the Ahmed decreases the risk of postoperative complications, it is less effective in lowering the eye pressure compared with a Baerveldt tube^4,5. 

There is a need for a glaucoma tube implant with similar efficacy to the Baerveldt but with a reduced complication rate, hence the Paul Glaucoma Implant was developed. 

How does the Paul Glaucoma Implant work? 

Like the Ahmed and Baerveldt tubes, the PGI is an aqueous shunt designed to reduce eye pressure. It can be used for patients with: 

• Medically uncontrolled glaucoma 
• Previous failed glaucoma surgery
• Secondary glaucoma, including neovascular, uveitic and traumatic glaucoma

The tube size of the PGI (0.1mm) is smaller compared to the Baerveldt and Ahmed tubes (0.3mm). The smaller tube size of the PGI is likely to decrease the risk of complications, including tube exposure, cornea damage and hypotony (low eye pressure). 

The plate size of the PGI is similar to the Baerveldt implant and larger than the Ahmed implant, hence it is likely that the efficacy of the PGI is similar to the Baerveldt and better than the Ahmed. 

Why was the Paul Glaucoma Implant created? 

PGI was created with one aim in mind — to design an implant that can achieve better outcomes for our glaucoma patients. After years of tireless research, we can now answer these pertinent questions: 

Does this implant have a higher success rate and lower complication rate than existing tube implants? 

In the clinical trials⁶ we conducted to study the efficacy of PGI one year after implantation, 93.2% achieved qualified success. 68.9% saw complete success. These results suggest that efficacy of the PGI is similar to the Baerveldt Glaucoma Implant and better than the Ahmed Glaucoma Valve, with a higher safety profile than the Baerveldt Glaucoma Implant.

Is it surgically easier to insert? 

The surgical technique for implanting the PGI is similar to the Baerveldt implant, with a higher level of complexity compared with the Ahmed Glaucoma Valve. Hence, it is important to find a surgeon who is skilled and trained in implanting the PGI to perform the surgery. 

Is it self-regulating to prevent too much or too little aqueous flow? 

Aqueous flow through the PGI is regulated with an internal suture in the lumen of the tube, so as to prevent the eye pressure from going too low in the early postoperative period. Subsequently, your surgeon will be able to increase the flow through the implant by removing this suture. With meticulous monitoring and management, your surgeon can titrate flow through the PGI after the surgery. 

Can it control eye pressure over time? 

In a study⁷ conducted at the Manchester Royal Eye Hospital in the UK, 90.1% were qualified successes and achieved an IOP of >5 a year later without the need for medication. I have patients whose eye pressure is still well-controlled (often without glaucoma medications!) a few years after implanting the PGI.

	PGI	Ahmed	Baerveldt
Mean IOP one year post-operation	13.2±3.3	16.57±3.35	14.76±2.5
Failure	5.4%	19.67%	12%

Importantly, can it improve the patient’s quality of life, eliminating the need for eye drops and future glaucoma surgeries? 

The same study found that the mean number of medications dropped from 3.61 ± 1.09 to 1.22 ± 1.21 post-operation. 

What are the risks of Paul Glaucoma Implant? 

As with other implants, potential postoperative complications include; 

• Hypotony 
• Tube occlusion 
• Shallow anterior chamber 
• Choroidal effusion 

However, your chances of getting side effects are highly dependent on factors like the severity of the condition and the skill of the surgeon. 

Conclusion

Every day, glaucoma is still robbing patients of their vision. While we still need safer and more effective surgical options for glaucoma, with newer devices like PGI developed with intelligent technology and improved surgical outcomes, I believe this puts us a few steps forward and gives us hope of preserving the vision of millions of glaucoma patients worldwide. 

If you have any questions regarding the condition or surgery, please feel free to drop me a message and I am more than happy to help. 

References 

1. Sng, C., Harasymowycz, P., & Barton, K. (2017). Microinvasive Glaucoma Surgery. Journal of ophthalmology, 2017, 9845018. https://doi.org/10.1155/2017/9845018
2. https://www.snec.com.sg
3. Christakis, P. G., Kalenak, J. W., Tsai, J. C., Zurakowski, D., Kammer, J. A., Harasymowycz, P. J., Mura, J. J., Cantor, L. B., & Ahmed, I. I. (2016). The Ahmed Versus Baerveldt Study: Five-Year Treatment Outcomes. Ophthalmology, 123(10), 2093–2102. https://doi.org/10.1016/j.ophtha.2016.06.035
4. Sng, C., Wang, J., & Barton, K. (2017). Caution in Using the XEN-augmented Baerveldt Surgical Technique. Journal of glaucoma, 26(11), e257. https://doi.org/10.1097/IJG.0000000000000637
5. Riva, I., Roberti, G., Oddone, F., Konstas, A. G., & Quaranta, L. (2017). Ahmed glaucoma valve implant: surgical technique and complications. Clinical ophthalmology (Auckland, N.Z.), 11, 357–367. https://doi.org/10.2147/OPTH.S104220
6. Koh, V., Chew, P., Triolo, G., Lim, K. S., Barton, K., & PAUL Glaucoma Implant Study Group (2020). Treatment Outcomes Using the PAUL Glaucoma Implant to Control Intraocular Pressure in Eyes with Refractory Glaucoma. Ophthalmology. Glaucoma, 3(5), 350–359. https://doi.org/10.1016/j.ogla.2020.05.001
7. Vallabh, N. A., Mason, F., Yu, J., Yau, K., Fenerty, C. H., Mercieca, K., Spencer, A. F., & Au, L. (2021). Surgical technique, perioperative management and early outcome data of the PAUL® glaucoma drainage device. Eye (London, England), 1–6. Advance online publication. https://doi.org/10.1038/s41433-021-01737-1