Environmental Impact on Ocular Health

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Article initiated by:
Abdelrahman M. Elhusseiny, MD, MSc, Dan Arreaza-Kaufman, Dylan.freeman, Hannah Istre-Wilz, Lisa Kelly, Fatma Shakarchi
All contributors:
Ahmad A. Aref, MD, MBA, Andrew Go Lee, MD, Arsham Sheybani, MD, Daniel B. Moore, MD, Hannah Istre-Wilz, Dylan.freeman, Dan Arreaza-Kaufman, Fatma Shakarchi, Flora Lum, MD
Assigned editor:
Review:
Assigned status Update Pending
.


Introduction

On February 8th, 2022, the intergovernmental panel on climate change (IPCC) released the most up-to-date report on climate change; detailing the impacts, adaptations, and vulnerabilities our communities will be facing during the climate crisis. This report re-established that human-caused greenhouse gas emissions have already increased the global average temperature by more than 1 degree Celsius above preindustrial levels. Due to ongoing emissions, we can expect the earth to continue to warm. According to this report, with an additional 0.5 degree increase in global average temperatures, we will begin to experience permanent impacts on our ecosystems[1] According to current risk stratification models, the earth is already experiencing moderate risk events, which have manifested as a surge in extreme weather events monitored over the last 50 years.[2]

Global temperature rise has already been linked to the increased prevalence of several diseases. For example, wildfire smoke, atmospheric dust, and particulate matter have led to damaged respiratory systems[3], rising temperatures have been linked to increased cardiovascular risk[4], and natural disasters resulting in the loss of wildlife habitats have brought about an increase in zoonotic diseases.[5] [6] [7] As temperatures continue to rise, the risk level associated with these illnesses rise as well.[8] Ocular diseases are not excluded from the effects of the changing climate. Through direct and indirect methods, several ophthalmologic diseases have been linked to the environmental impacts of climate change. This review will be a non-exhaustive list of the various ways the increase in global temperatures may affect the health of the eye.

Extreme weather events

There is substantial evidence that warming surface temperatures have contributed to quantifiable changes in the severity and frequency of extreme weather events.[9] Extreme weather events are an abrupt and highly visible way that we experience climate change and result in immediate health and safety risks to those affected. Models have been developed to assess the extent that anthropogenic (human-caused) climate change can be attributed to specific weather events occurring today.[10] [11] The increased frequency and severity of extreme weather events can be attributed to the enhanced radiative force, meaning that as the global surface temperature rises, more energy is available in the atmospheric system. This manifests as heat waves, droughts, extreme rainfall, and extreme storms, among other weather patterns.[9][12]

Heat waves and high ambient temperatures

Heat waves have particularly affected major US cities and are occurring three times more often than they did in the 1960s.[13] Several ocular diseases have been implicated in rising ambient temperatures associated with heat waves, including cataracts. The epidemiological link between cataract formation and UV radiation has been established in several studies.[14] [15] [16] Independent of that association, a link has also been drawn between ambient environmental temperatures and several forms of cataract.[17] [18] [19] [20] [21] [22] An epidemiological study pointed to a predominance of nuclear subtype cataract in tropical and subtropical areas, possibly linked to the high ambient temperature of that region.[23] In addition, a case-control study conducted in India found a relationship between heat-wave induced dehydration and increased incidence of pre-senile cataract,[24] although it is important to note this result was not replicated in subsequent studies.[25] [26] It is evident that current understanding of temperature related cataract formation appears to be multifactorial but poorly understood.[27]

Retinal pathology is also linked to increases in environmental heat. An 11-year nationwide population database investigating the associations between weather conditions and retinal detachments found that the incidence of detachment was significantly associated with seasonality and positively correlated with ambient temperatures.[28] Rhegmatogenous retinal detachment appears to be most closely associated with temperature and seasonality,[29] [30] [31] although that association is not always found.[32] [33] One study linked a significant increase in tractional retinal detachments the week following a heat wave in Quebec.[34]

Changes in temperature and rainfall are also linked to an increase in vector borne illnesses, such as Trachoma.[35] Trachoma a leading cause of preventable blindness of infectious origins worldwide.[36] It is most prevalent in Sub-Saharan Africa, where hot climate, minimal precipitation, and infrastructural concerns lead to suboptimal hygiene conditions that leave families vulnerable to infection.[37] It has been speculated that the continued human-induced climate changes across the continent could provide the impetus for an expanding distribution of the fly vector and therefore, the disease.[38][39] In addition, climate-related strains on existing infrastructure caused by floods, droughts, or other natural disasters, may contribute to worsening sanitary conditions, exacerbating the disease prevalence.[38] [39] Similarly, fungal keratitis trends are linked to high temperatures, increased rainfall, and prevalence of heat waves.[40] [41] [42] One study was able to draw an association between the local temperature rise associated with climate change and the increasing rates of fungal infections also seen in the area.[43]

Precipitation

Heavy precipitates are also expected to become more frequent and more intense as the globe continues to warm. The intensity of regional precipitation will depend on factors such as changes in atmospheric circulation, storm dynamics, and regional warming.[9] Flash flooding is expected to increase in frequency as precipitate exceeds the capacity of drainage systems, exposing water systems to contamination.[44] [45] An increase in flood water in combination with poor drainage infrastructure can predispose communities to several pathogens with ocular significance. Toxoplasmosis, which is well known to cause retinochoroiditis,[46] has been linked to several water contamination related outbreaks.[47] [48] [49] [50] One such study documented the largest outbreak of Toxoplasmosis reported in French Guiana, which occurred after an unusual flood with warm temperatures, possibly contributing to the size of the outbreak.[48] Other pathogens implicated in flood related outbreaks include acanthamoeba keratitis[51] and various helminth infections.[52] [53] [54]

Infrastructure limitations

Climate-related natural disasters place systems of operation under stress. This has been previously described in the sections discussing how precipitation can overwhelm drainage systems leading to floods, and climate-induced weather events can strain the hygienic infrastructure in sub-Saharan Africa, leading to a growing prevalence of Trachoma. Climate- related events are also known to interrupt vital supply chains globally, particularly impacting healthcare systems after severe weather events, such as Hurricane Maria.[55] [56] These extreme weather events are also likely to disrupt the cold chain, which transports goods required to be stored at lower temperatures. Cold chains are most famous for transporting vaccines, but are also responsible for transport of many other medications, including the glaucomatous eye drops Bimaprost, Lantaprost, and Travoprost,[57] meaning disruption of the cold chain could lead to widespread shortages of these commonly used glaucoma treatments.

UV radiation

Ultraviolet radiation (UVR) is a form of non-ionizing radiation emitted by the sun. The quantity of UVR that reaches the earths’ surface unreflected is modulated by several atmospheric factors, including ozone, cloud trends, ground surface reflectivity, altitude, and air pollution. Ozone particles in the stratosphere are fundamental in dispersing harmful amounts of UVR.[58] Depletion in the ozone layer was initially observed in the 1980s and subsequently linked to man-made ozone-depleting molecules. The Montreal protocol signed in 1987, was an international treaty that pledged to phase out the harmful ozone-depleting molecules and monitor the ozone’s recovery. Due to the success of this pledge, the ozone is expected to recover by the mid-21st century.[59] Changes in climate will have a variable effect on that recovery. Elevations in greenhouse gases have been shown to interact with catalytic processes in the stratosphere, overall producing an ozone-depleting effect, which could blunt the positive effects of the Montreal protocol.[60] Conversely, climate-related changes may also exhibit a decrease in UVR exposure due to increasing water vapor, increased air pollution, and formation of surface-level ozone (smog) dispersing the UVR.[61] Overall, we still have reason to be cautiously optimistic about the state of the stratospheric ozone in the future, but should be aware of the effects excess UVR, especially in populations living in regions that are expected to experience more droughts and decreased rainfall, which will increase those individuals UV exposure.

When UV rays hit the eye, the structures affected are determined by the wavelength. Shorter wavelengths are more biologically active and absorbed by the cornea. Longer wavelengths can reach the lens, contributing to cataract formation.[62] UV radiation has been linked to several ocular pathologies, including age-related macular degeneration,[63] [64] [65] pterygium,[66] [67] [68] Keratoconus,[69] [70] and Fuchs dystrophy.[71] In addition, oxidative stress thought to be a result of UV radiation has also been implicated in dry eye syndrome.[72] [73] Climatic droplet keratopathy, which is a chronic condition characterized by corneal deposits, is also thought to result from UV exposure, since it is so closely linked to personal exposure to outdoor elements.[74] [75]

Pollution and air quality

Air pollution is a significant global health concern linked to various diseases, including cardiopulmonary disease, neurologic disease, and cancer. [76] [77] [78] The primary drivers of air pollution are fossil fuel combustion, motor vehicles, industrial facilities, and forest fires.[79] Despite air quality standards, harmful levels of pollutants, including PM2.5 (particulate matter <2.5 μm in diameter), continue to impact both developing and industrialized countries. Nearly the entire global population breathes air that exceeds WHO guideline limits, with low and middle-income countries experiencing the highest exposures.[80] PM2.5, which can penetrate into the lungs and bloodstream, is associated with respiratory diseases and systemic conditions such as coronary artery disease, diabetes mellitus, chronic kidney disease, and preterm birth. [81] [82] [83] [84] Recent research suggests a link between air pollution, PM2.5, and ocular pathologies, including dry eye, cataract, uveitis, age-related macular degeneration (AMD), and glaucoma.[85] [86] [87] [88]

Glaucoma is a leading cause of blindness globally, and its prevalence is higher in urban areas, raising suspicions of a potential association with air pollution.[89] The exact mechanisms of glaucoma development remain unclear, but oxidative stress, inflammatory pathways, and microvascular changes have been implicated in the diseases caused by air pollution. It is hypothesized that PM2.5 accumulates in the lungs, activating inflammation and releasing inflammatory mediators. PM2.5 can also enter the bloodstream, causing systemic immune-mediated inflammation, oxidative stress, cellular dysfunction, and apoptosis.[90] [91]

Proposed Hypotheses

Evidence suggests that PM2.5 can translocate across the pulmonary epithelium, entering the bloodstream and causing systemic immune-mediated inflammation and oxidative stress. This, in turn, leads to cellular dysfunction and apoptosis.[91] Regarding ocular tissue and glaucoma, Chua et al. demonstrated that higher PM2.5 is associated with a thinner ganglion cell-inner plexiform layer complex. The proposed mechanism involves toxicity to ocular tissues mediated by NO, IL-8, and NLRP3, causing oxidative stress and pyroptosis in trabecular meshwork cells.[92]

In addition, Li et al. conducted a study in which mouse eyes and human trabecular meshwork cells were exposed to topical PM2.5. Cell viability, NLRP3/caspase-1 IL 1B, GSDMD expression, ROS production, and cell contractility were measured. The authors demonstrated an upregulation of the NLRP3 inflammasome, caspase-1, IL-1β, GSDMD protein levels, and elevated reactive oxygen species. This suggests that PM2.5 has a direct toxic effect on intraocular tissues mediated by oxidative stress and subsequent NLRP3 inflammasome-mediated pyroptosis in trabecular meshwork cells.[93] These proposed ocular mechanisms align with the existing research and inflammatory pathways implicated in PM2.5 toxic effects on other organ systems, including the heart, lungs, kidneys, and nervous system.

Effect on Intraocular Pressure

The impact of PM2.5 on intraocular pressure (IOP) remains unclear. In a study by Chua et al., PM2.5 was found to be associated with a thinner macular ganglion cell-inner plexiform layer, as measured by spectral domain optical coherence tomography.[92] However, no clinically relevant relationship between PM2.5 and IOP was demonstrated, suggesting potential direct neurotoxic or vascular effects.[92] While IOP is a significant risk factor for primary open-angle glaucoma (POAG), a considerable proportion of glaucoma patients present with normal-range IOP, indicating the involvement of pressure-independent mechanisms in glaucoma progression. These mechanisms may include oxidative stress and inflammatory pathways.

Most reviewed studies did not find a significant association between PM2.5 and IOP, suggesting the involvement of pressure-independent mechanisms. However, a study by Yang et al. reported a significant but weak relationship between long-term PM2.5 exposure and IOP in a large Chinese population.[94] This finding is further supported by data from the U.K. Biobank study, which linked PM2.5 exposure to mildly elevated IOP.[92] While these studies suggest a potential link between PM2.5 and IOP, further research is needed to elucidate the underlying mechanisms and establish a clearer understanding of the relationship between air pollution and IOP in the context of glaucoma.

Relevant studies

In our search on May 2023, we found a total of 14 studies evaluating the relationship between PM2.5 and glaucoma. These studies demonstrated a consistent association between PM2.5 and glaucoma. Wang et al. found glaucoma to be associated with lower socioeconomic level, older age, female gender, higher U.V. radiation, and air pollution, specifically PM2.5.[95] In 2021, Sun et al. investigated the relationship between PM2.5 and POAG in the Taiwanese population over five years. The study population was categorized into four groups based on WHO PM2.5 exposure standards and found increasing rates of POAG in each quartile (OR per level 1.193).[96] Another large study of over 9,000 infants conducted by Min et al. found an association between PM10 and childhood glaucoma. The research team similarly categorized the participants into quartiles based on exposure and found that the probability of childhood glaucoma increased with increasing PM10 quartiles.[97] Particulate matter is also associated with an increased incidence of acute glaucoma, according to Li et al.[98] Chiang et al. found a similar link between PM2.5 exposure and glaucoma in patients with diabetes (Odds ratio (OR) 1.7 between Q4 and Q1, 95% CI: 1.084-2.764)[99], and Grant et al. conducted a Canadian multicenter longitudinal study of over 30,000 adults, finding PM2.5 to be associated with glaucoma (OR 1.14, CI 1.01-1.29).[100]

Recent studies provide compelling evidence of a statistically significant link between PM2.5 and glaucoma. This association is likely mediated by a pressure-independent mechanism involving direct toxicity to ocular tissue caused by inflammatory mediators. The accumulation of PM2.5 in the alveoli and its subsequent impact on trabecular meshwork cells and the ganglion cell-inner plexiform layer have been implicated in glaucoma pathogenesis. These findings align with the well-established role of air pollution in inducing inflammation and oxidative stress in various organ systems.

However, the relationship between air pollution and IOP remains unclear, with some studies reporting modest increases in IOP while others finding no significant change. Further research is needed to investigate the complex interplay between air pollution, particulate matter, and IOP regulation in the context of glaucoma.

Considering the widespread impact of air pollution on billions of individuals worldwide, deepening our understanding of how particulate matter affects ocular health is imperative. More studies are needed to comprehensively evaluate the role of air pollution, specifically PM2.5, in the development and progression of glaucoma.

Earth Observations and Environmental Exposures

Earth observations, typically associated with environmental monitoring and global mapping, have increasingly found applications in diverse fields, including healthcare. [101] [102] In eye health, the integration of Earth observation (EO) data offers innovative solutions for understanding the environmental factors influencing ocular diseases, assessing healthcare infrastructure, enhancing our understanding of disease surveillance and epidemiology, enabling infrastructure assessments and mapping, and facilitating access to eye care services through integration with many other public health tools, such as teleophthalmology. This article explores the intersection of EO technologies and eye health, highlighting their potential benefits and applications.

Environmental conditions play a significant role in the development and progression of various ocular diseases. Factors such as air pollution, ultraviolet (UV) radiation exposure, climate patterns, and geographical location can impact ocular health outcomes.[103]

EO methods encompass a range of technologies, including satellite imagery, remote sensing, and geospatial analysis, which enable the monitoring and assessment of environmental parameters pertinent to ocular health. Through EO data, researchers gain access to real-time and historical information on air quality, UV radiation levels, climate variations, and geographical features, providing a holistic understanding of the environmental influences on ocular well-being.[104]

By utilizing EO data, researchers can document the intricate interplay between environmental exposures and ocular diseases. The utilization of EO-derived insights extends beyond mere correlation. By identifying hotspots of environmental risk through spatial analysis of EO data, targeted interventions can be implemented to reduce exposure levels and prevent the onset of ocular diseases in vulnerable populations.

Disease Surveillance and Epidemiology

Earth observation (EO) data play a vital role in the surveillance and epidemiological studies of ocular diseases, offering valuable insights into their prevalence, distribution, and potential risk factors.[102] Satellite imagery and remote sensing technologies have revolutionized the way researchers and public health authorities approach disease monitoring and management.

Satellite imagery allows for the precise mapping of geographical regions with high prevalence rates of specific health conditions, providing valuable spatial data that can inform targeted interventions and resource allocation.[105] By integrating EO data with demographic information and environmental parameters, researchers can develop sophisticated models to forecast the spatial distribution of ocular diseases.[106] These models not only help in identifying areas at higher risk but also enable proactive measures to be taken to mitigate the spread of diseases.

One significant advantage of EO-based surveillance is its capability to support early detection and rapid response to outbreaks of systemic and ocular diseases.[107] Timely identification of emerging health challenges is crucial for implementing effective public health measures and minimizing the impact of outbreaks. EO data, with its ability to monitor environmental changes and population dynamics, provides a valuable tool for early warning systems and facilitates prompt intervention strategies.[108]

Furthermore, the integration of EO data with other health surveillance systems enhances the overall understanding of the epidemiology of ocular diseases.[106] By analyzing long-term trends and patterns, researchers can identify underlying factors contributing to disease prevalence and develop targeted interventions to address them.

Healthcare Infrastructure Assessment

Assessing healthcare infrastructure is essential for delivering effective medical services to populations worldwide.[109] Earth observations provide valuable information for evaluating healthcare facilities, accessibility, and resource distribution. Satellite imagery and geospatial analysis tools help identify underserved areas lacking adequate eye care resources and infrastructure.[110] By pinpointing areas with limited access to ophthalmic services, policymakers can prioritize healthcare interventions and allocate resources efficiently to improve eye health outcomes.[111]

Satellite imagery allows for the visualization and analysis of healthcare facilities, including hospitals, clinics, and ophthalmic centers, across vast geographic regions.[108] Geospatial analysis tools further enhance this assessment by providing metrics on accessibility, such as travel time to the nearest eye care facility, and identifying underserved areas with limited access to ophthalmic services.[109] By pinpointing these areas, policymakers can prioritize healthcare interventions and allocate resources efficiently to address disparities in eye health care.

Moreover, Earth observation data facilitate the monitoring of changes in healthcare infrastructure over time.[112] By tracking the construction of new facilities or the expansion of existing ones, decision-makers can assess progress towards improving access to eye care services. This longitudinal perspective is essential for evaluating the effectiveness of healthcare policies and interventions aimed at enhancing eye health outcomes.

Teleophthalmology and Remote Sensing Technologies

Teleophthalmology, the practice of using telecommunication technologies for remote diagnosis and treatment of eye diseases, has emerged as a valuable tool for expanding access to eye care services, particularly in underserved areas.[113] Earth observation data enhance teleophthalmology by providing contextual information on environmental factors that may impact patients' eye health.[114]

Remote sensing technologies, such as satellite imagery and aerial photography, enable the capture of high-resolution images of both the affected population and their surrounding environment.[115] These images can be analyzed to assess environmental risk factors, such as air pollution or exposure to ultraviolet radiation, which may contribute to the development or progression of ocular diseases.[101] By integrating EO-derived data into teleophthalmic services, healthcare providers can tailor their interventions to address specific environmental challenges faced by patients, thereby improving the effectiveness of diagnosis and treatment.

Furthermore, satellite communication networks play a crucial role in supporting telemedicine initiatives in remote or underserved regions.[115] By facilitating real-time communication between patients and healthcare providers, these networks enable remote consultations, diagnosis, and treatment planning, reducing barriers to accessing specialized eye care services.[114] This integration of Earth observation data with teleophthalmology not only expands the reach of eye care but also enhances its quality by incorporating environmental considerations into clinical decision-making processes, facilitating access to specialized eye care services.

Earth observations offer a multifaceted approach to addressing challenges in eye health by providing insights into environmental factors, supporting disease surveillance efforts, assessing healthcare infrastructure, and enhancing teleophthalmology services. The integration of EO technologies with traditional healthcare practices holds promise for improving ocular health outcomes globally. As the field continues to evolve, collaboration between EO experts, healthcare professionals, and policymakers is crucial for harnessing the full potential of Earth observations in advancing eye care and promoting vision health equity.

Conclusions

The environment we interact with contributes to the health of the population. As this environment begins to change, so too will the prevalence and severity of a broad swath of ocular diseases. As the world begins to better understand the effects that global temperature rises will have on our communities, it is imperative to determine the climate risk as it relates to the eye. Namely, to what extent will we see an increase in these ocular diseases, and what impact will that have on a given patient population. Current studies have established a correlational relationship between many ocular diseases and the surrounding environment, but further research is needed to elucidate these interactions. As future research is done, special care should be placed on evaluating disease prevalence along lines of socioeconomic development and inequity driven by historic and ongoing colonialism, since the effects of the climate crisis are expected to disproportionally impact those marginalized communities. In addition, attention should be turned to understanding ways in which the healthcare system can mitigate their own contribution towards the continuing climate crisis.

Additional Resources

Understanding climate change:


Climate centered healthcare:

References

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