Glaucoma

 


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Am Fam Physician. 2016 Apr 15;93(8):668-674.

  Patient information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/diseases-conditions/glaucoma.html.

Author disclosure: The authors report that the development of this article was supported in part by an unrestricted departmental grant from Research to Prevent Blindness.

Glaucoma is a set of irreversible, progressive optic neuropathies that can lead to severe visual field loss and blindness. The two most common forms of glaucoma, primary open-angle glaucoma and primary angle-closure glaucoma, affect more than 2 million Americans and are increasing in prevalence. Many patients with glaucoma are asymptomatic and do not know they have the disease. Risk factors for primary open-angle glaucoma include older age, black race, Hispanic origin, family history of glaucoma, and diabetes mellitus. Risk factors for primary angle-closure glaucoma include older age, Asian descent, and female sex. Advanced disease at initial presentation and treatment nonadherence put patients with glaucoma at risk of disease progression to blindness. The U.S. Preventive Services Task Force has concluded that the evidence is insufficient to assess the potential benefits and harms of screening for glaucoma in the primary care setting. Regular eye examinations for adults are recommended by the American Academy of Ophthalmology, with the interval depending on patient age and risk factors. Diagnosis of glaucoma requires careful optic nerve evaluation and functional studies assessing a patient's visual field. The goal of treatment with eye drops, laser therapy, or surgery is to slow visual field loss by lowering intraocular pressure. Family physicians can contribute to lowering morbidity from glaucoma through early identification of high-risk patients and by emphasizing treatment adherence in patients with glaucoma.

Glaucoma is a group of optic neuropathies associated with characteristic structural changes at the optic nerve head that may lead to visual field loss and, ultimately, blindness. Blindness is most commonly defined as 20/200 or worse visual acuity on a Snellen eye chart or a visual field of less than 20 degrees. Legal blindness refers to the fulfillment of these criteria by the better-seeing eye. By 2020, approximately 79.6 million persons worldwide will have glaucoma and more than 11 million will be bilaterally blind from glaucoma.1 More than 2 million Americans 40 years and older have glaucoma, and studies of the U.S. population estimate that more than one-half of these cases may be undiagnosed or untreated.2,3 Among black and Hispanic persons, glaucoma is the leading cause of irreversible blindness. Glaucoma accounts for more than 25% of cases of blindness in these groups, making it a more common cause of blindness than diabetic retinopathy (accounting for 7.3% and 14.3% of cases in blacks and Hispanics, respectively) and age-related macular degeneration (accounting for 4.4% and 14.3% of cases in blacks and Hispanics, respectively). Among Hispanics, glaucoma causes blindness more often than cataracts do (28.6% vs. 14.3%).4 In 2009, Medicare beneficiaries spent $748 million on glaucoma-related visits, testing, and procedures.5 Patients with glaucoma who are not blind may have functional limitations, leading to driving cessation and decreased ability to read.6

WHAT IS NEW ON THIS TOPIC: GLAUCOMA

Recent meta-analyses have concluded that diabetes mellitus is associated with a greater risk of developing primary open-angle glaucoma and higher intraocular pressure.

The U.K. Glaucoma Treatment Study (a multicenter, randomized, placebo-controlled trial) recently showed longer visual field preservation in patients with primary open-angle glaucoma taking latanoprost (Xalatan).

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Fundus photography or intraocular pressure measurement alone is a poor screening tool to detect patients with glaucoma.

C

22

Family history of open-angle glaucoma, older age, and black race or Hispanic origin are important risk factors for open-angle glaucoma.

C

1, 31, 32, 36, 37, 4448, 50, 51

Early treatment of patients with glaucoma reduces the risk of visual field progression.

B

8


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Fundus photography or intraocular pressure measurement alone is a poor screening tool to detect patients with glaucoma.

C

22

Family history of open-angle glaucoma, older age, and black race or Hispanic origin are important risk factors for open-angle glaucoma.

C

1, 31, 32, 36, 37, 4448, 50, 51

Early treatment of patients with glaucoma reduces the risk of visual field progression.

B

8


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

The two most common forms

The Authors

show all author info

DIVAKAR GUPTA, MD, is a clinical associate in the Department of Ophthalmology at Duke University School of Medicine, Durham, N.C. At the time this article was written, he was a clinical instructor in the Department of Ophthalmology at the University of Washington Medical Center, Seattle....

PHILIP P. CHEN, MD, is a professor in the Department of Ophthalmology at the University of Washington Medical Center.

Address correspondence to Divakar Gupta, MD, Duke Eye Center, 2351 Erwin Rd., Durham, NC 27703 (e-mail: dg46@duke.edu). Reprints are not available from the authors.

Author disclosure: The authors report that the development of this article was supported in part by an unrestricted departmental grant from Research to Prevent Blindness.

REFERENCES

show all references

1. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol. 2006;90(3):262–267....

2. Friedman DS, Wolfs RC, O'Colmain BJ, et al.; Eye Diseases Prevalence Research Group. Prevalence of open-angle glaucoma among adults in the United States [published correction appears in Arch Ophthalmol. 2011;129(9):1224]. Arch Ophthalmol. 2004;122(4):532–538.

3. Shaikh Y, Yu F, Coleman AL. Burden of undetected and untreated glaucoma in the United States. Am J Ophthalmol. 2014;158(6):1121–1129.e1.

4. Congdon N, O'Colmain B, Klaver CC, et al.; Eye Diseases Prevalence Research Group. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol. 2004;122(4):477–485.

5. Quigley HA, Cassard SD, Gower EW, Ramulu PY, Jampel HD, Friedman DS. The cost of glaucoma care provided to Medicare beneficiaries from 2002 to 2009. Ophthalmology. 2013;120(11):2249–2257.

6. Ramulu P. Glaucoma and disability: which tasks are affected, and at what stage of disease? Curr Opin Ophthalmol. 2009;20(2):92–98.

7. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension Treatment Study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002;120(6):701–713, discussion 829–830.

8. Heijl A, Leske MC, Bengtsson B, Hyman L, Bengtsson B, Hussein M; Early Manifest Glaucoma Trial Group. Reduction of intraocular pressure and glaucoma progression: results from the Early Manifest Glaucoma Trial. Arch Ophthalmol. 2002;120(10):1268–1279.

9. The AGIS Investigators. The Advanced Glaucoma Intervention Study (AGIS): 7. The relationship between control of intraocular pressure and visual field deterioration. Am J Ophthalmol. 2000;130(4):429–440.

10. Vass C, Hirn C, Sycha T, Findl O, Bauer P, Schmetterer L. Medical interventions for primary open angle glaucoma and ocular hypertension. Cochrane Database Syst Rev. 2007(4):CD003167.

11. Distelhorst JS, Hughes GM. Open-angle glaucoma. Am Fam Physician. 2003;67(9):1937–1944.

12. Sigal IA, Ethier CR. Biomechanics of the optic nerve head. Exp Eye Res. 2009;88(4):799–807.

13. Alasil T, Wang K, Yu F, et al. Correlation of retinal nerve fiber layer thickness and visual fields in glaucoma: a broken stick model. Am J Ophthalmol. 2014;157(5):953–959.

14. Vitale S, Smith TD, Quigley T, et al. Screening performance of functional and structural measurements of neural damage in open-angle glaucoma: a case-control study from the Baltimore Eye Survey. J Glaucoma. 2000;9(5):346–356.

15. Congdon NG, Youlin Q, Quigley H, et al. Biometry and primary angle-closure glaucoma among Chinese, white, and black populations. Ophthalmology. 1997;104(9):1489–1495.

16. Wolfs RC, Grobbee DE, Hofman A, de Jong PT. Risk of acute angle-closure glaucoma after diagnostic mydriasis in nonselected subjects: the Rotterdam Study. Invest Ophthalmol Vis Sci. 1997;38(12):2683–2687.

17. Shindler KS, Sankar PS, Volpe NJ, Piltz-Seymour JR. Intermittent headaches as the presenting sign of subacute angle-closure glaucoma. Neurology. 2005;65(5):757–758.

18. Ringeisen AL, Harrison AR, Lee MS. Ocular and orbital pain for the headache specialist. Curr Neurol Neurosci Rep. 2011;11(2):156–163.

19. Lachkar Y, Bouassida W. Drug-induced acute angle closure glaucoma. Curr Opin Ophthalmol. 2007;18(2):129–133.

20. Kumar S, Giubilato A, Morgan W, et al. Glaucoma screening: analysis of conventional and telemedicine-friendly devices. Clin Experiment Ophthalmol. 2007;35(3):237–243.

21. Jeong da W, Kook MS, Lee KS, Lee JR, Han S. Circadian pattern of intraocular pressure fluctuations in young myopic eyes with open-angle glaucoma. Invest Ophthalmol Vis Sci. 2014;55(4):2148–2156.

22. Tielsch JM, Katz J, Singh K, et al. A population-based evaluation of glaucoma screening: the Baltimore Eye Survey. Am J Epidemiol. 1991;134(10):1102–1110.

23. Springelkamp H, Lee K, Wolfs RC, et al. Population-based evaluation of retinal nerve fiber layer, retinal ganglion cell layer, and inner plexiform layer as a diagnostic tool for glaucoma. Invest Ophthalmol Vis Sci. 2014;55(12):8428–8438.

24. Yamada N, Chen PP, Mills RP, et al. Screening for glaucoma with frequency-doubling technology and Damato campimetry. Arch Ophthalmol. 1999;117(11):1479–1484.

25. Gill JM, Cole DM, Lebowitz HM, Diamond JJ. Accuracy of screening for diabetic retinopathy by family physicians. Ann Fam Med. 2004;2(3):218–220.

26. Sussman EJ, Tsiaras WG, Soper KA. Diagnosis of diabetic eye disease. JAMA. 1982;247(23):3231–3234.

27. Moyer VA; U.S. Preventive Services Task Force.. Screening for glaucoma: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;159(7):484–489.

28. American Academy of Ophthalmology. Frequency of ocular examinations–2015. http://www.aao.org/clinical-statement/frequency-of-ocular-examinations--november-2009. Accessed April 10, 2015.

29. American Academy of Ophthalmology. AAO and AGS statement on the AHRQ comparative effectiveness of screening for glaucoma draft report –2011. http://www.aao.org/clinical-statement/aao-ags-statement-on-ahrq-comparative-effectivenes-3. Accessed January 26, 2016.

30. Burr JM, Mowatt G, Hernández R, et al. The clinical effectiveness and cost-effectiveness of screening for open angle glaucoma: a systematic review and economic evaluation. Health Technol Assess. 2007;11(41):iii–iv, ix–x, 1–190.

31. Wolfs RC, Klaver CC, Ramrattan RS, van Duijn CM, Hofman A, de Jong PT. Genetic risk of primary open-angle glaucoma. Population-based familial aggregation study. Arch Ophthalmol. 1998;116(12):1640–1645.

32. Tielsch JM, Katz J, Sommer A, Quigley HA, Javitt JC. Family history and risk of primary open angle glaucoma. The Baltimore Eye Survey. Arch Ophthalmol. 1994;112(1):69–73.

33. Rudnicka AR, Mt-Isa S, Owen CG, Cook DG, Ashby D. Variations in primary open-angle glaucoma prevalence by age, gender, and race: a Bayesian meta-analysis. Invest Ophthalmol Vis Sci. 2006;47(10):4254–4261.

34. Jiang X, Varma R, Wu S, et al.; Los Angeles Latino Eye Study Group. Baseline risk factors that predict the development of open-angle glaucoma in a population: the Los Angeles Latino Eye Study. Ophthalmology. 2012;119(11):2245–2253.

35. Varma R, Ying-Lai M, Francis BA, et al.; Los Angeles Latino Eye Study Group. Prevalence of open-angle glaucoma and ocular hypertension in Latinos: the Los Angeles Latino Eye Study. Ophthalmology. 2004;111(8):1439–1448.

36. Tielsch JM, Sommer A, Katz J, Royall RM, Quigley HA, Javitt J. Racial variations in the prevalence of primary open-angle glaucoma. The Baltimore Eye Survey. JAMA. 1991;266(3):369–374.

37. Wormald RP, Basauri E, Wright LA, Evans JR. The African Caribbean Eye Survey: risk factors for glaucoma in a sample of African Caribbean people living in London. Eye (Lond). 1994;8(Pt 3):315–320.

38. Leske MC, Connell AM, Schachat AP, Hyman L; The Barbados Eye Study. Prevalence of open angle glaucoma. Arch Ophthalmol. 1994;112(6):821–829.

39. Seah SK, Foster PJ, Chew PT, et al. Incidence of acute primary angle-closure glaucoma in Singapore. An island-wide survey. Arch Ophthalmol. 1997;115(11):1436–1440.

40. Lavanya R, Wong TY, Friedman DS, et al. Determinants of angle closure in older Singaporeans. Arch Ophthalmol. 2008;126(5):686–691.

41. Zhao D, Cho J, Kim MH, Friedman DS, Guallar E. Diabetes, fasting glucose, and the risk of glaucoma: a meta-analysis. Ophthalmology. 2015;122(1):72–78.

42. Zhou M, Wang W, Huang W, Zhang X. Diabetes mellitus as a risk factor for open-angle glaucoma: a systematic review and meta-analysis. PLoS One. 2014;9(8):e102972.

43. Cheng JW, Cheng SW, Ma XY, Cai JP, Li Y, Wei RL. The prevalence of primary glaucoma in mainland China: a systematic review and meta-analysis. J Glaucoma. 2013;22(4):301–306.

44. Fingert JH, Héon E, Liebmann JM, et al. Analysis of myocilin mutations in 1703 glaucoma patients from five different populations. Hum Mol Genet. 1999;8(5):899–905.

45. Arkell SM, Lightman DA, Sommer A, Taylor HR, Korshin OM, Tielsch JM. The prevalence of glaucoma among Eskimos of northwest Alaska. Arch Ophthalmol. 1987;105(4):482–485.

46. Chen PP. Risk and risk factors for blindness from glaucoma. Curr Opin Ophthalmol. 2004;15(2):107–111.

47. Friedman DS, Jampel HD, Muñoz B, West SK. The prevalence of open-angle glaucoma among blacks and whites 73 years and older: the Salisbury Eye Evaluation Glaucoma Study. Arch Ophthalmol. 2006;124(11):1625–1630.

48. Mitchell P, Smith W, Chey T, Healey PR. Open-angle glaucoma and diabetes: the Blue Mountains eye study, Australia. Ophthalmology. 1997;104(4):712–718.

49. de Voogd S, Ikram MK, Wolfs RC, et al. Is diabetes mellitus a risk factor for open-angle glaucoma? The Rotterdam Study. Ophthalmology. 2006;113(10):1827–1831.

50. Bowe A, Grünig M, Schubert J, et al. Circadian variation in arterial blood pressure and glaucomatous optic neuropathy--a systematic review and meta-analysis. Am J Hypertens. 2015;28(9):1077–1082.

51. Charlson ME, de Moraes CG, Link A, et al. Nocturnal systemic hypotension increases the risk of glaucoma progression. Ophthalmology. 2014;121(10):2004–2012.

52. Graham SL, Drance SM, Wijsman K, Douglas GR, Mikelberg FS. Ambulatory blood pressure monitoring in glaucoma. The nocturnal dip. Ophthalmology. 1995;102(1):61–69.

53. Marcus MW, de Vries MM, Junoy Montolio FG, Jansonius NM. Myopia as a risk factor for open-angle glaucoma: a systematic review and meta-analysis. Ophthalmology. 2011;118(10):1989–1994.e2.

54. Garway-Heath DF, Crabb DP, Bunce C, et al. Latanoprost for open-angle glaucoma (UKGTS): a randomised, multicentre, placebo-controlled trial [published correction appears in Lancet. 2015;386(9989):136]. Lancet. 2015;385(9975):1295–1304.

55. Glaucoma Laser Trial Research Group. The Glaucoma Laser Trial (GLT) and glaucoma laser trial follow-up study: 7. Results. Am J Ophthalmol. 1995;120(6):718–731.

56. Malihi M, Moura Filho ER, Hodge DO, Sit AJ. Long-term trends in glaucoma-related blindness in Olmsted County, Minnesota. Ophthalmology. 2014;121(1):134–141.

57. Chen PP. Blindness in patients with treated open-angle glaucoma. Ophthalmology. 2003;110(4):726–733.

58. Peters D, Bengtsson B, Heijl A. Lifetime risk of blindness in open-angle glaucoma. Am J Ophthalmol. 2013;156(4):724–730.

59. Sleath B, Blalock S, Covert D, et al. The relationship between glaucoma medication adherence, eye drop technique, and visual field defect severity. Ophthalmology. 2011;118(12):2398–2402.

60. Oliver JE, Hattenhauer MG, Herman D, et al. Blindness and glaucoma: a comparison of patients progressing to blindness from glaucoma with patients maintaining vision. Am J Ophthalmol. 2002;133(6):764–772.



 

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