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Editors Selection IGR 22-1
Epidemiology: Glaucoma and Diabetes Mellitus
Comment by Eugene A. Lowry & Steve Mansberger on:
77861 Increased risk of open-angle glaucoma among patients with diabetes mellitus: a 10-year follow-up nationwide cohort study, Rim TH; Lee SY; Bae HW et al., Acta Ophthalmologica, 2018; 0:
The authors investigate the incidence of open-angle glaucoma within a subpopulation from Korean national insurance data who have diabetes compared to a non-diabetic control group. Patients with diabetes are match 1:1 to non-diabetic patients controlling for basic demographic and clinical variables. Over ten years of follow-up from 2004 through 2013, the authors find a small but significant increased incidence of open-angle glaucoma in patients with diabetes (20/10,000 person years) compared with controls (17/10,000 person years), with a corresponding hazard ratio of 1.19. This increased risk was seen across age and sex groups.
The authors use a robust definition of glaucoma, requiring ICD codes in combination with billing for visual fields and topical therapy. They validate this definition with a manual review of 200 charts from two hospitals, with 188 patients (94%) have the diagnosis confirmed on chart review. Interestingly, the majority (152 patients, 78%) had normal-tension glaucoma, which may affect the generalizability of the study.
A major challenge of using insurance data sets to look at associations between diabetes and open-angle glaucoma is detection bias. Though patients with diabetes were matched to controls on the number of medical visits, the authors did not match on number of visits to eye care providers or number of dilated eye exams. Given practice guidelines, it is reasonable to wonder whether diabetic patients may have had more frequent dilated eye examinations than their matched controls with corresponding bias towards increased detection rates.
The association between diabetes with incidence and progression of open-angle glaucoma remains controversialOverall, the association between diabetes with incidence and progression of open-angle glaucoma remains controversial both in the direct effect of diabetes and impacts of systemic diabetic medications. Further studies, including a burgeoning literature on peripapillary vasculature, may help the mechanisms of any possible association and guide future clinical care.
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