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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
United States veterans are a highly understudied group of individuals
and are deserving of our highest level of care. Today, approximately 5
million veterans in the U.S. use the services of a VA medical facility
which provides many specialized medical programs and treatment
options unique to their needs . These include Blind Rehabilitation
Centers, Vision Impairment Services, and social work--needs that other
health care facilities are often unable or unwilling to meet.
Despite the availability of these services, 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 he quality of
veterans’ health outcomes.
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)
C/D
(±SD)
CCT
(±SD)
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.
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)
Secondary 69.48 (11.28) 18.77 (9.57) 0.62 (0.26) 555.27 (66.67)
(4.6)
72.05 (10.41) 17.23 (5.48) 0.59 (0.29) 554.47 (50.89)
NAG/ACG
(4.3)
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)
Table 1: Risk Factors Based on Types of Glaucoma
(1)Name:
DALLAS GLAUCOMA REGISTRY
_____ (2) Hospital No.: ___________ (3) Date first seen in Dallas _________
(1)Date of last exam
MATERIALS AND METHODS
IOP
(±SD)
RESULTS AND DISCUSSION
Type
(%)
(5) DOB _
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.
__
(6) Sex: 1 | 2 1= M, 2 = F
(7) Hosp.: 1 | 2 | 3 | 4 1 = Aston, 2 = PMH, 3 = VA, 4 = JPS
Study Design and Participant Selection:
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:
• 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).
(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;
(10) Glaucoma Diagnosis (A) OD: 0│1 | 2 | 3 | 4 | 5 │6│7_|
│ 1 | 2 | 3 | 4 | 5 │6│7 |
Figure 2
(B) OS: 0
CONCLUSIONS
• Glaucoma suspects were the most prevalent group (46.8%) and
were treated much less frequently by either medication or surgery
than the other groups.
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__________________
•VF defects (A) OD 0 | 1 | 2 | 3 (B) OS 0 | 1 | 2 | 3 0 = normal, 1 = mild, 2 = moderate, 3 = severe
(13) C/D ratio (A) OD ________ (B) OS ________
• Of the 1463 POAG eyes, 465 (31.8%) had severe VF defects, 581
(39.7%) were treated by 3 or more medications and 408 (27.9%)
required surgery.
(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 __________________
• Of the 167 eyes diagnosed with secondary glaucoma, 49 (29.3%)
were due to surgery and 42 (25.1%) had a history of trauma.
•Initially diagnosed in Dallas? 1 | 2 | 1 = yes, 2 = no
•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 ____________________
REFERENCES
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
• Number of medications: ______________
• Glaucoma suspect: 1 | 2 | 3 | 4 | 5 1 = increased IOP, 2 = suspicious disc(s), 3 = strong family history,
suspicious VF or NFL, 5 = other ___________
4=
•Secondary glaucoma: 1 | 2 | 3 | 4 | 5 1 = rubeotic, 2 = traumatic, 3 = inflammatory, 4 = post-surgical,
5 = other _______
SUPPORT
•ACG/NAG: 1 | 2 | 3 | 4 1 = primary acute angle closure, 2 = plateau iris, 3 = chronic angle closure, 4 = CMG, 5 =
others _________________________
This research is supported in part by an unrestricted grant from
the Society to Prevent Blindness New York, NY.
(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
Glaucoma in United States Veterans:
An Overlooked Group?
Priyanka Kamath, MS; Zohra Prasla, BBA; Matthew Harrison, BS;
Karanjit Kooner, MD
Authors have no financial conflict in this study
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
•United States veterans are a highly understudied group of individuals
•Approximately 5 million veterans in the U.S. use the services of a VA medical
facility ex: Blind Rehabilitation Centers, Vision Impairment Services, and social
work
•Despite the availability of these services, the VA Health Service has more than
300,000 patients afflicted with glaucoma, the second leading cause of blindness
•The incidence of blindness is more than 10 times higher in veterans as
compared to the general population
•At the Dallas Veterans Affairs Medical Center (VAMC), 30% of 250 blind patients
were so due to glaucoma
•Due to very little information on glaucoma in veterans, the data collected for
this study will provide healthcare professionals with invaluable information
regarding glaucoma in this patient population thereby improving he quality of
veterans’ health outcomes
MATERIALS AND METHODS
Study Design and Participant Selection:
•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
•The 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:
 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)
MATERIALS AND METHODS
Data Collection and Analysis:
•Data was gathered by reviewing medical charts and completing a custom form
for each patient (See Figure 1)
•Information was recorded 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
•Risk factors were then analyzed based on four glaucoma subtypes: Primary
Open Angle Glaucoma (PAOG), Suspect, Secondary, and Narrow Angle
Glaucoma/Angle Closure Glaucoma (NAG/ACG)
•Means and standard deviations were used 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)
Figure 1: Form Used to Collect Data From Patients Charts
DALLAS GLAUCOMA REGISTRY
(1) Name:
_____ (2) Hospital No.: ___________ (3) Date first seen in Dallas _________
Date of last exam
(5) DOB _
__
(6) Sex: 1 | 2 1= M, 2 = F
(7) Hosp.: 1 | 2 | 3 | 4 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;
(10) Glaucoma Diagnosis (A) OD: 0│1 | 2 | 3 | 4 | 5 │6│7_|
| 5 │6│7 |
(B) OS: 0 │ 1 | 2 | 3 | 4
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__________________
VF defects (A) OD 0 | 1 | 2 | 3 (B) OS 0 | 1 | 2 | 3 0 = normal, 1 = mild, 2 = moderate, 3 = severe
Initially diagnosed in Dallas? 1 | 2 | 1 = yes, 2 = no
(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 __________________
Glaucoma medications: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9
Figure 1: Form Cont’d
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 ____________________
Number of medications: ______________
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 1 = rubeotic, 2 = traumatic, 3 = inflammatory, 4 = postsurgical,
5 = other _______
ACG/NAG: 1 | 2 | 3 | 4 1 = primary acute angle closure, 2 = plateau iris, 3 = chronic angle closure,
4 = CMG, 5 = others _________________________
(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______________
Table 1: Risk Factors Based on Types of Glaucoma
Type (%)
Age
(±SD)
IOP
(±SD)
C/D (±SD)
CCT
(±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)
Secondary
(4.6)
69.48 (11.28)
18.77 (9.57)
0.62 (0.26)
555.27 (66.67)
NAG/ACG
(4.3)
72.05 (10.41)
17.23 (5.48)
0.59 (0.29)
554.47 (50.89)
RESULTS AND DISCUSSION
•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
•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.
(See Figure 2)
•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. (See Figure 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.
Figure 2
Figure 3
CONCLUSION
•Glaucoma suspects were the most prevalent group (46.8%) and were treated
much less frequently by either medication or surgery than the other groups
•Of the 1463 POAG eyes, 465 (31.8%) had severe VF defects, 581 (39.7%) were
treated by 3 or more medications and 408 (27.9%) required surgery
•Of the 167 eyes diagnosed with secondary glaucoma, 49 (29.3%) were due to
surgery and 42 (25.1%) had a history of trauma
REFERENCES
Marcussen, BL, Newcomb RD. Mil Med1994
Jan;159(1):10-5.
Quigley HA, Broman AT. The number of people
with glaucoma worldwide in 2010 and
2020. Br J Ophthalmol. 2006;90:262–267