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The Rational Clinical Examination | Clinician's Corner

Do Findings on Routine Examination Identify Patients at Risk for Primary Open-Angle Glaucoma?  The Rational Clinical Examination Systematic Review

Hussein Hollands, MD, MSc (Epid); Davin Johnson, MD; Simon Hollands, BSc; David L. Simel, MD, MHS; Delan Jinapriya, MD, FRCSC; Sanjay Sharma, MD, MBA, MSc
JAMA. 2013;309(19):2035-2042. doi:10.1001/jama.2013.5099.
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Importance Glaucoma is the second leading cause of blindness worldwide, and its insidious onset is often associated with diagnostic delay. Since glaucoma progression can often be effectively diminished when treated, identifying individuals at risk for glaucoma could potentially lead to earlier detection and prevent associated vision loss.

Objective To quantify the diagnostic accuracy of examination findings and relevant risk factors in identifying individuals with primary open-angle glaucoma (POAG), the most common form of glaucoma in North America.

Data Sources Structured Medline (January 1950-January 2013) search and a hand search of references and citations of retrieved articles yielding 57 articles from 41 studies.

Study Selection Population-based studies of high-level methods relating relevant examination findings of cup-to-disc ratio (CDR), CDR asymmetry, intraocular pressure (IOP), and demographic risk factors to the presence of POAG.

Results The summary prevalence of glaucoma in the highest-quality studies was 2.6% (95% CI, 2.1%-3.1%). Among risk factors evaluated, high myopia (≥6 diopters; odds ratio [OR], 5.7; 95% CI, 3.1-11) and family history (OR, 3.3; 95% CI, 2.0-5.6) had the strongest association with glaucoma. Black race (OR, 2.9; 95% CI, 1.4-5.9) and increasing age (especially age >80 years; OR, 2.9; 95% CI, 1.9-4.3) were also associated with an increased risk. As CDR increased, the likelihood for POAG increased with a likelihood ratio (LR) of 14 (95% CI, 5.3-39) for CDR of 0.7 or greater. Increasing CDR asymmetry was also associated with an increased likelihood for POAG (CDR asymmetry ≥0.3; LR, 7.3; 95% CI, 3.3-16). No single threshold for CDR or asymmetry ruled out glaucoma. The presence of a disc hemorrhage (LR, 12; 95% CI, 2.9-48) was highly suggestive of glaucoma, but the absence of a hemorrhage was nondiagnostic (LR, 0.94; 95% CI, 0.83-0.98). At the commonly used cutoff for high IOP (≥22), the LR was 13 (95% CI, 8.2-17), while lower IOP made glaucoma less likely (LR, 0.65; 95% CI, 0.55-0.76). We found no studies of screening examinations performed by generalist physicians in a routine setting.

Conclusions and Relevance Individual findings of increased CDR, CDR asymmetry, disc hemorrhage, and elevated IOP, as well as demographic risk factors of family history, black race, and advanced age are associated with increased risk for POAG, but their absence does not effectively rule out POAG. The best available data support examination by an ophthalmologist as the most accurate way to detect glaucoma.

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Figure 1. Production and Outflow of Aqueous Humor in the Healthy Eye and an Eye With Primary Open-Angle Glaucoma
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Figure 2. Optic Disc in a Healthy Eye and an Eye With Advanced Glaucomatous Cupping
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The cup-to-disc ratio is approximated by comparing the vertical size of the cup to the size of the optic disc.

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Figure 3. Standard Automated Perimetry
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All images are right eyes. Note that visual fields are from perspective of patient, with lighter areas representing higher sensitivity and darker areas representing reduced sensitivity. Blindspot is located temporally corresponding to nasal location of optic nerve.

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