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o State-of-the-art surgery offers Asian eye patients new hope - Medical Tribute, 1 - 15 October 2005


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o The Singapore Malay Eye Study (SiMES) – Official Launch

Invitations will be sent to each selected individual. A trained team of recruiters will then follow-up with telephone calls and, if necessary, home visits to personally invite the participants for the study. The examination will include a detailed interview to assess medical history and lifestyle factors, a general examination (e.g., height, weight, and blood pressure), a clinical eye examination (e.g. vision, measurement of eye pressure) and eye photography.

SiMES will be the first large-scale study of its kind to be conducted for a Malay community sample in the world. SiMES will provide important and previously unavailable information on the frequency of the most important eye diseases affecting Malay Singaporeans, which will aid in prevention and treatment of these eye conditions.

SiMES is a Singapore Eye Research Institute (SERI) research program funded by a $500,000 grant from the National Medical Research Council (NMRC), and will be conducted in collaboration with participation from the Singapore National Eye Centre, National University Hospital, National University of Singapore and the Ministry of Health. SiMES is also strongly supported by both Yayasan Mendaki and the Islamic Religious Council of Singapore (MUIS), with both organisations actively advising and participating in this project.

DETAILS OF SiMES

1. Specific Aims
The study is a population-based, cross-sectional, epidemiological study aimed at determining the prevalence and risk factors of visual impairment, blindness and major eye conditions in adult Malays aged 40 to 79 years living in Singapore. Specific aims of the current study are to determine, in adult Malay people living in Singapore, the

1. Frequency and causes of bilateral and unilateral visual impairment and blindness
2. Frequency and risk factors of myopia (short sightedness) and other refractive errors, such as hyperopia (long sightedness), anisometropia (difference in refraction between right and left eyes) and astigmatism (irregular refraction)
3. Frequency and types (open, closed) of glaucoma, and their associations with myopia, eye and systemic risk factors.
4. Frequency and risk factors of age-related cataract and different types of cataract, and the overall utilization of cataract surgery
5. Frequency and risk factors of diabetic retinopathy, age-related macular degeneration and other retinal diseases
6. Association of retinal vascular signs to glaucoma, diabetic retinopathy and other conditions

2. Background

• The frequency and risk factors of visual impairment, blindness and cataract have been documented in China,1-4 and India.5-8
• In India, several studies have also reported on the epidemiology of myopia,9 glaucoma,10,11 diabetic retinopathy,12 and other diseases.13
• Relatively less data on these conditions in South East Asia are available. To address this, we initiated the Singapore Eye Disease Study (SEDS) programme, which is conducted in several stages in Chinese, Malays and Indians.
• The Tanjong Pagar Survey was conducted in Singapore in 1996-97. The Survey successfully examined and reported the prevalence and risk factors of glaucoma,14, myopia,15-18 cataract,19,20 and other diseases,21 among adult Chinese aged 40-79 years old. See below
• However, there is relatively little information on the epidemiology of low vision or major blinding eye diseases in people of Malay origin.22,23 A small number of studies in Singapore have suggested that Malays may have a different spectrum of ocular diseases.
• Myopia in children and young adults,24-26 acute angle closure glaucoma,27 and retinal detachment,28,29 appear to be less common in Malays compared to Chinese and Indians.
• In contrast, Malays appear to have higher rates of severe ocular trauma,30 and possibly diabetic retinopathy.31 However, there is no large population-based study in Malays.
• SiMES therefore builds on the experience and knowledge obtained from the Tanjong Pagar Survey. SiMES will document the burden and risk factors of visual impairment and eye diseases in Malay people.
• The data will offer key insights into the etiology of the most common age-related eye diseases and also provide information for allocation of public health resources for nearly 300 million Malay people living in Asia alone.

3. Methods
SiMES will examine a total of 3,200 Malay adults aged 40-80 years. The participants are pre-selected through random sampling of designated residential districts in the Southern Central part of Singapore located in close proximity to the study clinic. SiMES is planned to run from August 2004 to December 2006.

Participants will receive the following examination:

• Interview
• Blood pressure, Height, Weight, Hip-Waist Circumference
• Ankle brachial index, vibration sense and fine touch
• Autorefraction and subjective refraction
• Visual Acuity (VA) Measurements
• Ocular Biometry (Measurement of eyeball size)
• Slit Lamp Examination of anterior part of the eye
• Intraocular pressure assessment
• Visual Field Examination
• Pupil Dilatation
• Cataract grading
• Retinal and Optic Disc Examination
• Lens Photography
• Retinal photography
• Blood collection

• Bilateral low vision and bilateral blindness was found in 1.1% and 0.5% of the subjects. The rates of bilateral low vision and blindness increased with age. Cataract accounted for 60% of bilateral low vision and 20% of bilateral blindness. Glaucoma contributed to 60.0% of bilateral blindness.
• Glaucoma affects 3% of study population. Higher intraocular pressure (IOP) was an important determinant of glaucoma risk, and higher IOP was related to higher systolic blood pressures and increased corneal thickness.
• One in three participants had cataract. In those above 60 years, 8 of 10 people have age-related cataract. Diabetes, lower body mass index, cigarette smoking and lower socio-economic status were associated with cataract.
• Four of ten had myopia, and one in ten had high myopia.

5. Study Team
We have assembled an experienced and high-qualified team to undertake this project.

• Dr Wong Tien Yin, as PI, has a MD/PhD and dual training in ophthalmology and epidemiology. He has published more than 100 peer-reviewed papers in all aspects of ocular epidemiology and holds US NIH-funded grants for his current research. He was awarded the NUS 2004 Outstanding Researcher of the Year
• A/Prof Saw Seang Mei, the Co-PI, is an ophthalmic epidemiologist and the world’s leading authority in the epidemiology of myopia. She is the PI the Sumatra Eye Survey, and has more than 70 peer-reviewed papers. A/Prof Tan, the Co-PI, is the Director of SERI, and Deputy Director of SNEC. He holds numerous NMRC and BMRC grants.
• Dr Mohammed Rosman, Dr Loon Seng Chee and Dr Loo Jing Liang are young investigators who will lead the study in the clinic and home examinations.
• In addition, an eminent team of External Advisory Board member (Professors James Tielsch, Ronald Klein and Barbara Klein, Drs Paul Foster and Jie Jin Wang) will provide expertise and advice in this study. These members have conducted the ground-breaking Beaver Dam Eye Study, Baltimore Eye Study, and Blue Mountains Eye Study.

Details

6. SUMMARY
SiMES will provide the following

• Data on prevalence of visual impairment, blindness and major eye diseases in Malays will greatly assist planning of ophthalmic services for Singapore.
• Risk factor studies will provide insights into the etiology of eye diseases in Malays, which may lead to new therapeutic and preventive approaches to tackle these conditions
• Optimal methods of population screening for major eye diseases will be developed from knowledge obtained from this study
• Extrapolation of data to Malaysia, Indonesia and other countries with Malay-Muslim people

1. Zhao J, Jia L, Sui R, Ellwein LB. Prevalence of blindness and cataract surgery in Shunyi County, China. Am J Ophthalmol. 1998;126:506-14.
2. Li S, Xu J, He M, Wu K, Munoz SR, Ellwein LB. A survey of blindness and cataract surgery in Doumen County, China. Ophthalmology. 1999;106:1602-8.
3. He M, Xu J, Li S, Wu K, Munoz SR, Ellwein LB. Visual acuity and quality of life in patients with cataract in Doumen County, China. Ophthalmology 1999;106:1609-15.
4. Zhao J, Sui R, Jia L, Fletcher AE, Ellwein LB. Visual acuity and quality of life outcomes in patients with cataract in Shunyi County, China. Am J Ophthalmol. 1998;126:515-23.
5. Murthy GV, Gupta S, Ellwein LB, Munoz SR, Bachani D, Dada VK. A population-based eye survey of older adults in a rural district of Rajasthan: Central vision impairment, blindness, and cataract surgery. Ophthalmology. 2001;108:679-85.
6. Thulasiraj RD, Rahamathulla R, Saraswati A, Selvaraj S, Ellwein LB. The Sivaganga eye survey: I. Blindness and cataract surgery. Ophthalmic Epidemiol 2002;9:299-312.
7. Nirmalan PK, Thulasiraj RD, Maneksha V, Rahmathullah R, Ramakrishnan R, Padmavathi A, Munoz SR, Ellwein LB. A population based eye survey of older adults in Tirunelveli district of south India: blindness, cataract surgery, and visual outcomes. Br J Ophthalmol. 2002;86:505-12.
8. Michon JJ, Lau J, Chan WS, Ellwein LB. Prevalence of visual impairment, blindness, and cataract surgery in the Hong Kong elderly. Br J Ophthalmol 2002;86:133-9.
9. Dandona R, Dandona L, Srinivas M, Giridhar P, McCarty CA, Rao GN. Population-based assessment of refractive error in India: the Andhra Pradesh eye disease study. Clin Experiment Ophthalmol. 2002;30:84-93.
10. Dandona L, Dandona R, Mandal P, Srinivas M, John RK, McCarty CA, Rao GN. Angle-closure glaucoma in an urban population in southern India. The Andhra Pradesh eye disease study. Ophthalmology. 2000;107:1710-6.
11. Dandona L, Dandona R, Srinivas M, Mandal P, John RK, McCarty CA, Rao GN. Open-angle glaucoma in an urban population in southern India: the Andhra Pradesh eye disease study. Ophthalmology. 2000;107:1702-9.
12. Dandona L, Dandona R, Naduvilath TJ, McCarty CA, Rao GN. Population based assessment of diabetic retinopathy in an urban population in southern India. Br J Ophthalmol. 1999;83:937-40.
13. Dandona R, Dandona L. Corneal blindness in a southern Indian population: need for health promotion strategies. Br J Ophthalmol. 2003;87:133-41.
14. Foster PJ, Oen FT, Machin D, Ng TP, Devereux JG, Johnson GJ, Khaw PT, Seah SKL. The prevalence of glaucoma in Chinese residents of Singapore: A cross-sectional population survey of the Tanjong Pagar district. Arch Ophthalmol 2000;118:1105-11.
15. Wong TY, Foster PJ, Hee J, Ng TP, Tielsch JM, Chew SJ, Johnson GJ, Seah SKL.. Prevalence and risk factors for refractive errors in adult Chinese in Singapore. Invest Ophthalmol Vis Sci 2000;41:2486-94.
16. Wong TY, Foster PJ, Ng TP, Tielsch JM, Johnson GJ, Seah SKL. Variations in ocular biometry in an adult Chinese population in Singapore: The Tanjong Pagar Survey. Invest Ophthalmol Vis Sci 2001;42:73-80.
17. Wong TY, Foster PJ, Johnson GJ, Klein BEK, Seah SKL. The relationship between ocular dimensions and refraction with adult stature: The Tanjong Pagar Survey. Invest Ophthalmol Vis Sci 2001;42:1237-42.
18. Wong TY, Foster PJ, Johnson GJ, Seah SKL. Education, socioeconomic status, and ocular dimensions in Chinese adults: The Tanjong Pagar Survey. Br J Ophthalmol 2002;86:963-8.
19. Seah SKL, Wong TY, Foster PJ, Tze Pin Ng, Johnson GJ. The prevalence of cataract in Chinese residents in Singapore: The Tanjong Pagar Survey. Ophthalmology 2002 (In press)
20. Wong TY, Foster PJ, Johnson GJ, Seah SKL. Refractive errors, axial ocular dimensions and age-related cataracts: The Tanjong Pagar Survey. Invest Ophthalmol Vis Sci 2003;44:1479-85.
21. Wong TY, Foster PJ, Johnson GJ, Seah SKL, Tan DTH. The prevalence and risk factors for pterygium in adult Chinese population in Singapore: The Tanjong Pagar Survey. Am J Ophthalmol 2001;131:176-83.
22. Wong TY, Tan DTH. The SERI-ARVO Meeting and future challenges of ophthalmic research in Asia. British Journal of Ophthalmology 2003;87:379-80
23. See JL, Wong TY, Yeo KT. Trends in the pattern of blindness and major ocular diseases in Singapore. Ann Acad Med Singapore 1998;27:540-6.
24. Seet B, Wong TY, Tan DTH, Saw SM, Balakrishnan V, Lee LKH, Lim ASM. Myopia in Singapore: taking a public health approach. Br J Ophthalmol 2001;85:521-6.
25. Wu HM, Seet B, Yap EP, Saw SM, Lim TH, Chia KS. Does education explain ethnic differences in myopia prevalence? A population-based study of young adult males in Singapore. Optom Vis Sci 2001;78:234-9.
26. Au Eong KG, Tay TH, Lim MK. Race, culture and Myopia in 110,236 young Singaporean males. Singapore Med J 1993;34:29-32.
27. Wong TY, Foster PJ, Seah SKL, Chew PTK. Rates of hospital admissions for primary angle closure glaucoma among Chinese, Malays and Indians in Singapore. Br J Ophthalmol 2000;84:990-2.
28. Wong TY, Tielsch JM, Schein OD. Racial difference in the incidence of retinal detachment in Singapore. Arch Ophthalmol 1999;117:379-83.
29. Rosman M, Wong TY, Ong SG, Ang CL. Retinal detachment in Chinese, Malay and Indian residents in Singapore: a comparative study on risk factors, clinical presentation and surgical outcomes. Int Ophthalmol 2002;24:101-6.
30. Wong TY, Tielsch JM. A population-based study on the incidence of severe ocular trauma in Singapore. Am J Ophthalmol 1999;128:345-51.
31. Khoo DH, Tan KT, Yeo KT, Chew W, Yong V, Tan YT. Diabetic retinopathy--results of a two year screening programme in two medical units in Singapore. Ann Acad Med Singapore 1990;19:484-8.