Ocular Manifestations of Climate Change

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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]


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

Climate change and air quality are closely interconnected. The primary driver of climate change is combustion of fossil fuels resulting in greenhouse gas emissions including particulate matter (PM), ozone, nitrogen dioxide, and sulfur dioxide. These emissions, among other particles, are primarily responsible for reduction of air quality.[76][77] Morbidity related to ambient air pollution has grown in recent years[78] and according to recent estimates, more than 90% of the world’s population resides in locations where the WHO air quality guidelines were not met.[79] In 2016, poor air quality was estimated to cause 4.2 million premature deaths.[80]

Air pollution has also been implicated in several ocular surface diseases. Two recent reviews have been published[81][82] detailing the interplay between air pollution and eye diseases. Multiple studies have described an increased prevalence of dry eye syndromes associated with poor air quality, particularly with PM2.5.[83][84][85][86] Current understanding of this pathophysiology points to a combination of inflammatory responses and oxidative stress triggered by particulate matter.[81] PM has also been associated with uveitis,[87] cataract,[88][89] and age related macular degeneration.[90]

Final thoughts

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.

Further reading:

Understanding climate change: https://www.ipcc.ch/report/ar6/wg2/

Climate centered healthcare: https://climatecouncil.noharm.org/ https://www.hsph.harvard.edu/c-change/issues/climate-md/

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