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Editors Selection IGR 17-4

Glaucoma as cause of blindness: What are the major risk factors for blindness from POAG ?

Comment by David Friedman on:

69218 Risk Factors Associated with Progression to Blindness from Primary Open-Angle Glaucoma in an African-American Population, Pleet A; Sulewski M; Salowe RJ et al., Ophthalmic Epidemiology, 2016; 23: 248-256

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The authors present an age- and sex-matched case-control study of African Americans who are older than 35 years of age, with primary open-angle glaucoma being treated in the University of Pennsylvania Health System (UPHS). Cases were blind as defined by visual acuity (VA) of 20/200 or worse using Snellen acuity; no visual field criteria were used to define blindness. Those with any treatment outside UPHS were excluded, resulting in a total of 48 subjects being included; 37 unilaterally blind and 11 bilaterally. Fifty-nine control subjects were age- and sex-matched, had VA better than 20/200 and had received all care at UPHS. Cases and controls were similar in all general health aspects as well as estimated household income. The authors used multiple definitions of non-adherence including missed visits and whether or not the chart included documentation of non-adherence at a clinical visit.

Of note, a third of those blind either presented blind or were blind within a month of diagnosis. Blind patients were younger at diagnosis (62 versus 67 years of age), had higher mean intraocular pressure (IOP) (29 versus 21 mmHg), and worse baseline vision (median 20/80 versus 20/20). Blind patients had higher IOP at follow-up despite more medications and interventions. Doctors questioned adherence more frequently in the charts of those who were blind than in controls, but whether or not this was based on difficulty controlling IOP is not clear. The proportion of missed visits was similar between cases and controls.

Of note, a third of those blind either presented blind or were blind within a month of diagnosis

In multivariable regression analysis, having vision worse than 20/40 at diagnosis dramatically increased the likelihood of blindness over follow-up as did having IOP above 21 mmHg at more than 20% of visits and missing more than two visits per year on average. The authors note that those who were blind had more advanced disease at diagnosis with worse vision, higher IOP and a greater likelihood of missing follow-up visits. Despite more treatments to lower IOP among those who ended up blind, IOP was less well controlled over follow-up. While this paper is a case-control study and clinical recommendations cannot be based on these findings alone, the findings support the recommendation from the Collaborative Initial Treatment in Glaucoma Study for more aggressive treatment in those with more advanced glaucoma at presentation.

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