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Glaucoma in United States Veterans:
An Overlooked Group?
Priyanka Kamath, MS; Zohra Prasla, BBA; Matthew Harrison, BS;
Karanjit Kooner, MD
Dallas Veterans Affairs Medical Center
4500 South Lancaster Road
Dallas, TX 75216
Department of Ophthalmology, University of Texas Southwestern Medical Center
Dallas, TX 75390
INTRODUCTION
Approximately 5 million veterans in the U.S. use the services of VA
medical facilities which provides many specialized medical programs and
treatment options unique to their needs . In ophthalmology, these
include routine and specialized eye care, Blind Rehabilitation Centers,
Vision Impairment Services, and social work—needs.
The VA Health Service has more than 300,000 patients afflicted with
glaucoma, the second leading cause of blindness .2 Also, the incidence of
blindness is more than 10 times higher in veterans as compared to the
general population. 1At the Dallas Veterans Affairs Medical Center
(VAMC), 30% of 250 blind patients were so due to glaucoma.
Unfortunately, there is very little information on glaucoma in veterans.
Thus, the data collected for this study will provide healthcare
professionals with invaluable information regarding glaucoma in this
patient population thereby improving the quality of veterans’ health
outcomes.
Type
(%)
Age
(±SD)
POAG
(40.6)
74.15 (10.60) 15.98 (4.85) 0.71 (0.21) 538.02 (69.35)
Suspects
(46.8)
67.01 (11.68) 17.17 (4.28) 0.55 (0.19) 548.90 (43.57)
NAG/ACG
(4.3)
• Patients who have been seen two or more times by an
ophthalmologist at the Dallas VAMC
• Patients with sufficient necessary information in their medical chart,
including gender, race, diagnosis, visual field records, IOP
measurements, medications prescribed, etc.
• Patients who have primary or secondary glaucoma (not tertiary to
other disease processes).
Data Collection and Analysis:
Data was gathered by reviewing medical charts and completing a
custom form for each patient. (Figure 1) We recorded information on
ocular characteristics such as intraocular pressure (IOP), central corneal
thickness (CCT), cup-to-disk ratio (C/D), medications, surgeries, visual
fields (VF), and visual acuity (VA) as well as demographic data such as
age, gender, and ethnicity. Each patient was enrolled only once in the
registry, regardless of the number of clinic visits.
We analyzed several risk factors based on four glaucoma subtypes:
Primary Open Angle Glaucoma (PAOG), Suspect, Secondary, and
Narrow Angle Glaucoma/Angle Closure Glaucoma (NAG/ACG). We used
means and standard deviations to characterize quantitative variables
and percentages to describe categorical variables. The data was
transferred to Microsoft Excel (Microsoft Corporation, Seattle, WA,
USA) and risk factors were analyzed using SAS 9.2v (SAS Institute, Cary,
NC, USA) and SPSS (SPSS Inc., an IBM Company, Chicago, IL, USA).
Visual Field Defects in POAG
Patients
23%
23%
20%
34%
Mild
Moderate
Severe
No Defect or Defect Secondary to Other Cause
__
(6) Sex: 1 | 2 1= M, 2 = F
1 = Aston, 2 = PMH, 3 = VA, 4 = JPS
(8) Race: 1 | 2 | 3 | 4 | 5 | 6
1 = White, 2 = Black, 3 = Hispanic, 4 = Asian, 5 = East Indian, 6 = N/A, 7 = other
(9) Glaucoma status 1 | 2 | 3 1 = stable, 2 = undetermined, 3 = unstable;
• Glaucoma suspects were the most prevalent group (46.8%) in this
study.
0= normal; 1 = POAG; 2 = LTG/NTG; 3 = glaucoma suspect; 4 = secondary; 5 = ACG/NAG,
6= childhood; a) primary; b) secondary; c) juvenile; 7=other__________________
•Initially diagnosed in Dallas?
(B) OS 0 | 1 | 2 | 3
The NAG/ACG group was least prevalent (4.3%). However, they had the
highest number of surgeries (76.6 %) compared to POAG (26.7%),
secondary (26.1%), and suspects (1.8%).
a history of trauma.
CONCLUSIONS
Figure 2
(10) Glaucoma Diagnosis (A) OD: 0│1 | 2 | 3 | 4 | 5 │6│7_|
(B) OS: 0 │ 1 | 2 | 3 | 4 | 5 │6│7 |
•VF defects (A) OD 0 | 1 | 2 | 3
In this study of 1800 patients (3600 eyes), glaucoma suspect was the
most prevalent diagnosis (46.8%). These patients were on average the
youngest of all four groups and had the smallest average C/D ratio
(0.55). Interestingly, however, suspicious optic disk (SOD) was the
most common risk factor for these patients followed by elevated IOP.
Eyes diagnosed with secondary glaucoma were the third most
prevalent (4.6%). Of these, 49 (29.3%) had glaucoma secondary to
surgery and 42 (25.1%) had glaucoma secondary to trauma. (Figure 3)
DALLAS GLAUCOMA REGISTRY
_____ (2) Hospital No.: ___________ (3) Date first seen in Dallas _________
(5) DOB _
RESULTS AND DISCUSSION
The second most prevalent group was POAG (40.6%). The mean C/D
ratio for POAG was 0.71, which was higher than secondary, suspect,
and NAG/ACG (0.62, 0.55, and 0.29, respectively). In addition, the
average number of medications taken was 2.21 for POAG, 1.68 for
secondary, 1.55 for NAG/ACG, and 0.56 for suspect. 465 (31.8%) POAG
eyes had visual field (VF) defects that were described as “severe,” or in
other words, had a mean defect greater than -12. (Figure 2)
Table 1: Risk Factors Based on Types of Glaucoma
(7) Hosp.: 1 | 2 | 3 | 4
From July 2005 to July 2009, The Dallas Glaucoma Registry (DGR) has
compiled epidemiological data for over 4,000 glaucoma patients seen
at UT Southwestern Medical Center and its affiliated clinics in the
North Texas region. Our research population consisted of 1800 United
States military veterans, both male and female, who have been
followed for glaucoma or a risk of developing glaucoma at the Dallas
VAMC. We included the following:
CCT
(±SD)
72.05 (10.41) 17.23 (5.48) 0.59 (0.29) 554.47 (50.89)
(1)Date of last exam
Study Design and Participant Selection:
C/D
(±SD)
Secondary 69.48 (11.28) 18.77 (9.57) 0.62 (0.26) 555.27 (66.67)
(4.6)
(1)Name:
MATERIALS AND METHODS
IOP
(±SD)
Causes of Secondary
Glaucoma
0 = normal, 1 = mild, 2 = moderate, 3 = severe
1 | 2 | 1 = yes, 2 = no
• Of the POAG eyes, nearly a third had severe VF defects, 40% were
treated by 3 or more medications and more than a quarter required
surgery.
(13) C/D ratio (A) OD ________ (B) OS ________
(14) Glaucoma surgery: (A) OD 1 | 2 | 3 | 4 | 5 | 6 | 7 (B) OS 1 | 2 | 3 | 4 | 5 | 6 | 7
1 = ALT/SLT, 2 = LPI, 3 = trabeculectomy, 4 = glaucoma shunt, 5 = cyclodestruction, 6 = no surgery,
7 = other __________________
13%
15%
•Glaucoma medications: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9
1 = prostaglandin analogues (Xalatan, Travatan, Lumigan, Rescula), 2 = beta blockers (Timoptic, Betimol,
Betoptic, Betagan, Carteolol, Istalol), 3 = alpha agonist (Iopidine, Alphagan 0.2%, 0.15%, 0.1%),
4 = topical CAI (Trusopt 2%, Azopt 1%), 5 = system CAI (Neptazane 25 mg, /50 mg, Diamox
250/500mg),
6 = sympathomimetic (Propine), 7 = miotics (Pilocarpine 2%, 4%, 6%, Carbochol .75%, 1.5%, 3%),
8 = no meds, 9 = other ____________________
• Of the eyes diagnosed with secondary glaucoma, nearly 30% were
post intraocular surgery and a quarter had a history of trauma.
28%
33%
1. Marcussen, BL, Newcomb RD. Mil Med1994 Jan;159(1):10-5.
2. Quigley HA, Broman AT. The number of people with glaucoma
worldwide in 2010 and 2020. Br J Ophthalmol. 2006;90:262–267
11%
• Number of medications: ______________
REFERENCES
• Glaucoma suspect: 1 | 2 | 3 | 4 | 5 1 = increased IOP, 2 = suspicious disc(s), 3 = strong family history,
4 = suspicious VF or NFL, 5 = other ___________
•Secondary glaucoma: 1 | 2 | 3 | 4 | 5
5 = other _______
1 = rubeotic, 2 = traumatic, 3 = inflammatory, 4 = post-surgical,
•ACG/NAG: 1 | 2 | 3 | 4 1 = primary acute angle closure, 2 = plateau iris, 3 = chronic angle closure, 4 = CMG,
others _________________________
SUPPORT
5=
Rubeotic
Traumatic
Post-Surgical
Other
(20) Vision Best Corrected (A) OD: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 |
(B) OS 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 |
1= 20/20, 2= 20/40, 3=20/60, 4= 20/80, 5=20/100, 6= 20/200, 7= CF, 8= HM, 9=LP, 10=NLP, 11=Prosthesis
(21) IOP (mmHg) (A) OD _____________ (B) OS _____________
(22) CCT (µ): (A) OD____________ (B) OS______________
Figure 1: Form Used To Collect Data From Patient Charts
Figure 3
Inflammatory
This research is supported in part by an unrestricted grant from
the Society to Prevent Blindness New York, NY.