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Editors Selection IGR 8-4

Quality of life

Comment by Cristina Leske on:

13418 Age-related eye disease, visual impairment, and survival: the Beaver Dam Eye Study, Knudtson MD; Klein BE; Klein R, Archives of Ophthalmology, 2006; 124: 243-249

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Are patients with open-angle glaucoma at increased risk of death, as some studies suggest, whether from associated diseases, treatment side effects, or other causes? Knudtson et al. (2) in the Beaver Dam Eye Study, a valuable source of epidemiologic data, addressed this question by determining mortality risks of age-related ocular conditions during a 14-year period. After accounting for relevant risk factors, a worse survival was linked to cataract, diabetic retinopathy and visual impairment, but not to open-angle glaucoma. While these are reassuring results for glaucoma patients, what is their interpretation?

Other well-conducted population-based studies have also not confirmed earlier reports of reduced survival in glaucoma. However, conclusions were limited by the relatively short follow-up or small number of glaucoma patients in some studies. The comprehensive Beaver Dam data were carefully analyzed and offer the major advantage of prolonged follow-up, thus strengthening the evidence that glaucoma does not increase mortality.

Glaucoma is not associated with increased mortality

As with all non-significant findings, low study power to detect associations is possible, especially since glaucoma was the least frequent of the conditions analyzed. However, results suggest that missed mortality effects, if any, would be small. Another caveat concerns the 'glaucoma' definition used, which included both definite and probable disease. Definite glaucoma required ≥ 2 of 3 criteria: visual field defects by Henson perimetry, cup-disc ratio > 0.7 and intraocular pressure > 21 mmHg; probable glaucoma required only a history of treatment, without the previous criteria. Ocular hypertension could potentially be classified as 'glaucoma' by this definition.

Future studies of mortality may consider separate evaluations of ocular hypertension and glaucoma. Ocular hypertension could increase cardiovascular mortality because systemic hypertension and diabetes are related to high intraocular pressure. In contrast, these two conditions have not been related consistently to glaucoma. Ideally, future studies would use glaucoma definitions independent of intraocular pressure and have sufficient patients to allow examining subcategories, e.g., normal tension glaucoma.

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