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Epidemiology of glaucoma: What's new?

ARTICLE in CANADIAN JOURNAL OF OPHTHALMOLOGY JUNE 2012
Impact Factor: 1.33 DOI: 10.1016/j.jcjo.2012.02.003 Source: PubMed

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Epidemiology of glaucoma: whats new?

Colin Cook, FCS(Ophth)SA*, Paul Foster, FRCOphth
ABSTRACT RSUM
Globally, there are an estimated 60 million people with glaucomatous optic neuropathy and an estimated 8.4 million people who are blind
as the result of glaucoma. These numbers are set to increase to 80 million and 11.2 million by 2020. Glaucoma is the second leading
cause of blindness globally. The highest prevalence of open-angle glaucoma occurs in Africans, and the highest prevalence of
angle-closure glaucoma occurs in the Inuit. Population-based screening for open-angle glaucoma is not recommended. Screening for
angle-closure may be feasible.
lchelle mondiale, lon estime 60 millions le nombre de personnes atteintes dune neuropathie optique glaucomateuse et 8,4
millions le nombre de ccits dues au glaucome. Ces donnes sapprtent augmenter jusqu 80 millions et 11,2 millions en 2020. Le
glaucome est la deuxime cause principale de ccit dans le monde. La prvalence la plus leve du glaucome angle ouvert se situe
chez les Africains et la prvalence la plus leve du glaucome angle ferm se situe chez les Inuits. Le dpistage des populations pour
le glaucome angle ouvert nest pas recommand. Le dpistage angle ferm peut tre faisable.

Definition of glaucoma

A definition of glaucoma for use in epidemiologic studies was agreed on in 1998, and that definition is still in
use.1 Glaucoma is defined as an optic neuropathy that is
characterized by specific structural findings in the optic
disc and specific functional deficits detected by automated
visual field testing. Raised intraocular pressure (IOP) is still
recognized as an important risk factor, but it is not a defining characteristic of the disease.
Glaucomatous optic neuropathy results from loss of neural
tissue and from posterior bowing of the lamina cribrosa. The
vertical cup-disc ratio (VCDR) can be used as an index of
neuroretinal rim loss, and the 97.5th percentile of the VCDRs
of the normal population could be considered the upper limit
of normal. From the available evidence, a VCDR of 0.7 is the
97.5th percentile cut-off in all ethnic groups studied.2 If the
VCDR is used alone, 2.5% of the normal population would
be defined as having glaucoma. To make this more robust, if
visual field testing is not possible and the VCDR is used alone,
the 99.5th percentile is used as the cutoff. A VCDR of 0.8 is
used as the cutoff for the 99.5th percentile.
A field abnormality is considered if, on a Zeiss-Humphrey
field analyzer plot using a threshold program with a 24-2 test
pattern, there is an abnormal glaucoma hemifield test or a
reproducible cluster of 3 nonedge points abnormal at the 5%
level and of typical glaucomatous distribution.
Prevalence of glaucoma

There are 3 levels of evidence that can be used for the

diagnosis of glaucoma in cross-sectional surveys (Table 1).1
Presented at the annual meeting of the Canadian Ophthalmology Society, June 2011, Vancouver, BC
From the *Division of Ophthalmology, University of Cape Town, Cape
Town, Republic of South Africa, and the Moorfields Eye Hospital,
London, England.

A number of glaucoma prevalence surveys have been

done in various racial groups (Table 2).3-32 There are several problems in making meaningful comparisons among
the surveys. They include variations in the methodology,
in the quality of the data, and in the criteria used to identify
cases. Quigley and colleagues published pooled-data analyses of glaucoma prevalence data in 1996 and in 2006.33,34
In the 2006 paper, they note the following:

Sixty million people are affected by glaucomatous

optic neuropathy.
Three-quarters of these people have open-angle glaucoma.
Women are affected more than men (55% of openangle glaucoma, 70% of angle-closure glaucoma, and
59% of all glaucoma).
Asians are the largest group affected, comprising
47% of the total with all types of glaucoma and 87%
of primary angle-closure glaucoma.
Primary angle-closure glaucoma is more common in
Chinese people.
Japanese people have the highest rates of glaucoma
occurring within the statistically normal range of
IOP for the population.
The prevalence of primary open-angle glaucoma in
white Europeans, Americans, and Australians is
similar.
Africans in Africa, the Caribbean, and the United
States have a higher prevalence of primary openangle glaucoma than do Asians and Europeans.

Can J Ophthalmol 2012;47:223226

0008-4182/11/$-see front matter 2012 Canadian Ophthalmological Society.

Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jcjo.2012.02.003

Originally received Jan. 26, 2012. Accepted Mar. 27, 2012

Correspondence to Colin Cook, Division of Ophthalmology, H53 OMB,
Groote Schuur Hospital Observatory, 7925, Cape Town, South Africa;
colin.cook@uct.ac.za
CAN J OPHTHALMOLVOL. 47, NO. 3, JUNE 2012

223

Epidemiology of glaucomaCook & Foster

Table 1Levels of evidence for the diagnosis of glaucoma in
cross-sectional surveys
Level

Table 3Risk factors for primary open-angle glaucoma

Race

African people have a prevalence up to 5 times

higher than other ethnic groups.
Hispanic people have a more pronounced
increase with age
There is an exponential increase with increased
age.
There is an increased risk with high refractive
error, both myopia and hypermetropia.
There is an increased risk with thin central
corneal thickness.
There is an increased risk with a large optic disc
diameter.
There is an increased risk for onset and
progression with elevated IOP, and a decreased
risk for progression with lowering of IOP.
There is less risk in young persons with
hypertension and increased risk in older
persons with hypertension.
This was previously considered to be a risk factor
but is no longer.
Cardiovascular disease and glaucoma are
probably closely related.
There is an increased risk for low ocular
perfusion pressure with low physical activity.

Evidence
VCDR or VCDR asymmetry 97.5th percentile of the normal
population plus visual field defect compatible with glaucoma
Severely damaged disc (VCDR 99.5th percentile of the normal
population) plus no reliable visual field obtainable
No view of optic disc plus IOP 99.5th percentile of the normal
population or evidence of previous filtering surgery

1
2
3

Age
Refractive error
Central corneal
thickness
Optic disc diameter

IOP, intraocular pressure; VCDR, vertical cup-disc ratio.

Intraocular pressure

The prevalence of glaucoma is projected to increase

with population growth and the aging of the population, and by 2020 it is expected that the number of
affected people will have risen to 80 million.

Prevalence of blindness from glaucoma

Glaucoma is the second leading cause of blindness

globally, after cataract. The 2010 global estimates are
that 4.5 million people are blind due to open-angle
glaucoma and 3.9 million are blind due to angle-closure
glaucoma. These numbers are set to rise to 5.9 and 5.3
million, respectively, by 2020. Angle-closure glaucoma
causes a greater proportion of blindness than open-angle
glaucoma.34
Some surveys of glaucoma prevalence report the proportions of people with glaucoma who are blind. These

Blood pressure

Diabetes mellitus
Cardiovascular
disease
Physical activity
IOP, intraocular pressure.

numbers vary from none in Sweden23 to 22% in South

Africa.5 Data from blindness-prevalence surveys for
which cause-specific data are given offer similar numbers of people bilaterally blind as the result of glaucoma.33,35

Table 2Glaucoma prevalence surveys in various racial groups

Racial Group
African
African origin

African mixed origin

East Asian Asian
origin

Indian
European origin

American Hispanic

Year of
Publication

Location

PACG (%)

POAG (%)

Secondary Glaucoma

Reference

0.59
0.1

3.1
2.7
1.4
8.8
4.74
7.1
1.5

0.15
1.7
0.35
A few
1.42
Not stated
0.81

4
5
6
7
8
9
10

1.26
0.24

1.00
Nil
Not stated
Not stated
0.48
Not stated
0.3
0.57
0.21
0.11
0.26
Not stated
0.34
4.97
0.68
Not stated
0.41
Nil
0.15
0.29
0.3
0.2
0.02

11
12
13
14
15
16
17
18
19,20
19,20
21
22
23
24
8
25
26
27
28
29
30
31
32

2000
2002
1969
1989
1991
1994
1993

Kongwa, Tanzania
Hlabisa, South Africa
Jamaica
St Lucia
Baltimore, U.S.
Barbados
Mamre, South Africa

40
40
35-74
30
40
40-84
40

1973
1987
1988
1989
1991
1996
1996
2000
1999

Umanaq, Greenland
Alaska
Alaska
Beijing, China
Japan
Taiwan
Hovsgol, Mongolia
Singapore
Hyderabad, India

1966
1980
1981
1991
1991
1992
1994
1994
1996
1997
1998
1998
2001

Ferndale, Wales
Framingham, U.S.
Dalby, Sweden
Middle Norway
Baltimore, U.S.
Beaver Dam, U.S.
Roscommon, Ireland
Rotterdam, Netherlands
Blue Mountains, Australia
Ponza, Italy
Egna-Neumarkt, Italy
Melbourne, Australia
Tucson, U.S.

40
40
40
40
40
40
40
40-79
30
40
40-74
52-85
55-69
65
40
43-84
50
55
49
40
40
40
40

PACG, primary angle-closure glaucoma; POAG, primary open-angle glaucoma.

224

Age Range

CAN J OPHTHALMOLVOL. 47, NO. 3, JUNE 2012

Nil
Nil
0.67
Not stated
2.3
4.8
2.65
3.8
1.4
0.34
3.0
1.4
1.14
0.71
1.08
0.09
Not stated
Nil
Not stated
0.31
0.04
0.09
Nil
0.27
0.97
0.6
0.1
0.1

Nil
0.03
2.62
Not stated
0.5
1.79
1.62
2.56
0.43
1.9
0.86
3.37
1.29
2.1
1.88
1.1
3.0
2.51
2.0
1.7
1.97

Epidemiology of glaucomaCook & Foster

Table 4 Risk factors for primary angle-closure glaucoma

Screening for glaucoma

Race

Mongoloid people have a higher prevalence.

Age
Sex
Family history

There is increased
There is increased
There is increased
history.
There is increased

Screening for glaucoma must include tests for both

open-angle glaucoma and angle-closure glaucoma. A
screening test for open-angle glaucoma should be valid
(with high sensitivity and specificity), reliable, inexpensive,
rapid, and acceptable. Measurement of IOP and VCDR
are 2 tests that are routinely used when screening for primary open-angle glaucoma. They are continuous variables,
with no cutoff point that discriminates adequately between
normal eyes and eyes with glaucoma. There is no satisfactory combination of sensitivity and specificity for either
test.45 A visual field defect does not become detectable
until nearly 50% of the optic nerve fibres have atrophied. It
is a subjective test, and it may be unreliable. Therefore,
screening of the general population for primary open-angle
glaucoma using tonometry, disc examination, or visual
field examination cannot be recommended at the present
time. Instead, the emphasis should be on opportunistic
screening of people at risk (for example, older Africans).
This is of interest and is important in low- and middleincome African countries where as much as 90% of cases of
primary open-angle glaucoma may be undiagnosed and up
to 50% of patients may already be blind in 1 eye at presentation.46
To screen for primary angle-closure glaucoma, 3 tests
have been proposed that look for a shallow anterior chamber and an occludable angle: the oblique flashlight test, the
limbal anterior chamber depth test, and the axial anterior
chamber depth test.47-49 The oblique flashlight test does
not require a slit lamp, but it may be difficult to standardize. The limbal anterior chamber depth test and the axial
anterior chamber depth test do require a slit lamp, with all
the limitations that this imposes. Gonioscopy is required
to confirm the diagnosis, and biometric gonioscopy using a
reticule in the slit lamps eye piece has been found to be
useful.50 This is of interest and is of particular importance
in areas of Canada and other locales where Inuit populations reside.

Refractive error

risk with increased age.

risk in females.
risk with a positive family
risk with hypermetropia.

Incidence of glaucoma and glaucoma blindness

Knowing the prevalence of eye disease and blindness

is useful when advocating for allocation of resources for
eye care and blindness prevention. Knowing the incidence is more useful for planning services. However,
incidence data are more difficult to obtain than prevalence data.
To report observed incidence, it is necessary to conduct
a cross-sectional survey, wait a number of years, and then
re-examine the same population. The cumulative incidence is calculated as the number of new cases in that time
period, divided by the total population at risk. In a predominantly white population in Melbourne, Australia, the
5-year incidence of definite open-angle glaucoma was
0.5% and of probable and definite open-angle glaucoma
was 1.1%.36 In a predominantly black population in Barbados, the 9-year incidence of definite open-angle glaucoma was 4.4%, or 0.5% per year.37 In both studies, the
incidence rose with increasing age.
Estimates of incidence can be calculated from prevalence data by using mathematical models.38,39 Based on a
mathematical model, in the United States, the cumulative
probability of open-angle glaucoma in white persons is
4.2% and in black persons is 10.3%.40
It would be useful to know the incidence of blindness
resulting from glaucoma, but these data are not available.
In a study in Uganda, the annual incidence of visual loss
resulting from glaucoma was 0.04%.41
Geographic distribution of glaucoma

The data in Table 1 give an indication of the differences

in prevalence rates and predominant types of glaucoma in
various populations and differing geographic areas.
Primary open-angle glaucoma is more common in Africans than it is in Europeans or Asians. In the United States,
the age-adjusted prevalence rate of primary open-angle
glaucoma in African Americans is 4 to 5 times higher than
it is in European Americans. The highest reported prevalence rates of primary open-angle glaucoma are in the black
populations of the Caribbean.7,9
Angle-closure glaucoma is more common in Asians than
it is in Africans or Europeans. There is variation in the
prevalence in the various areas in Asia; the highest prevalence rates recorded are found in surveys of the Inuit.11-13
The risk factors for primary glaucoma are presented in
Tables 3 and 4.3,42-44

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