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Editors Selection IGR 9-4

Glaucoma and Systemic Disease: Statin use, hyperlipid emia and glaucoma

Comment by Fotis Topouzis on:

50575 The Relationship Between Statin Use and Open-Angle Glaucoma, Stein JD; Newman-Casey PA; Talwar N et al., Ophthalmology, 2012; 119: 2074-2081

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Stein et al. investigated the relationship between statin use and open-angle glaucoma (OAG) in a retrospective, longitudinal, cohort analysis of 524,109 individuals aged ≥ 60 years with hyperlipidemia enrolled in a national United States managed care network. Among those individuals 316,182 (60%) had ≥ 1 prescription for a statin. Based on multivariate Cox regression analysis they found that the hazard of developing OAG decreased 0.3% for every additional month of statin consumption. Individuals who took statins continuously for two years had an 8% decreased OAG risk compared to those who received no statins. The hazard of progressing from a diagnosis of glaucoma suspect to OAG decreased 0.4% and 9% respectively. In addition, the hazard of requiring medical treatment for OAG decreased 0.4% for every additional month of statin use. Based on these results they conclude that statin use was associated with a significant reduction in the risk of OAG among persons with hyperlipidemia. As with all retrospective cohorts relying on managed care databases, this study has certain strengths and weaknesses. Strengths include its large sample size and the fact that patients in this study come from communities throughout the United States. Limitations include: the data source used does not contain clinical information and inherently OAG diagnosis was not based on standardized glaucoma definition, possibly inducing misclassification bias. In addition, the analysis could not consider results of laboratory testing, such as levels of lipids. Therefore, one should be cautious while interpreting the results of this study. It is not possible to determine whether it is the reduced hyperlipidemia under statins treatment or the medications used to treat hyperlipidemia (statins) that may be responsible for the reduced risk of OAG found in this study. The dose-response effect that was observed could not help in interpretation since there may be a confounding by lipids level status. Also, the use of statins maybe subject to poor adherence. The authors argue that poor adherence should bias their findings to the null, and yet supporting their findings of statins to be protective against OAG. However, lipids levels status maybe a confounding to poor adherence. Use of IOP lowering treatment may not be a surrogate for glaucoma development, since indication for IOP lowering treatment may rely on ocular hypertension diagnosis. These data are noteworthy, however, to develop hypotheses that can be tested in future prospective studies including subjects without hyperlipidemia, subjects with hyperlipidemia and subjects with hyperlipidemia and use of statins.

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