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Open-angle glaucoma: Epidemiology, clinical presentation, and diagnosis Author Deborah S Jacobs, MD Section Editor Jonathan Trobe

, MD Deputy Editor Pracha Eamranond, MD, MPH Disclosures Last literature review version 19.3: Fri Sep 30 00:00:00 GMT 2011 | This topic last updated: Tue Feb 15 00:00:00 GMT 2011 (More) INTRODUCTION — Glaucoma is a group of eye diseases traditionally characterized by elevated intraocular pressure (IOP). However, glaucoma is more accurately defined as an optic neuropathy than a disease of high pressure. In open-angle glaucoma, optic nerve damage results in a progressive loss of retinal ganglion cell axons, which is manifested initially as visual field loss and, ultimately, irreversible blindness if left untreated [1]. This topic will discuss the epidemiology, clinical presentation, and diagnosis of openangle glaucoma in adults. Glaucoma in children, angle-closure glaucoma, and treatment and prevention of open-angle glaucoma are discussed elsewhere. (See "Overview of glaucoma in infants and children" and "Angle-closure glaucoma" and "Open-angle glaucoma: Treatment".) CLASSIFICATION — There are different types of glaucoma, generally categorized by the anterior chamber (iridocorneal) angle (figure 1) and the underlying etiology, if known:  Open-angle glaucoma is an optic neuropathy characterized by progressive peripheral visual field loss followed by central field loss, in a characteristic pattern. This is usually but not always in the presence of elevated intraocular pressure (IOP), perhaps in part related to increased aqueous production and decreased outflow (figure 2). The optic nerve or "disc" takes on a hollowed-out appearance on ophthalmoscopic examination, which is described as "cupping." Cupping is associated with the loss of ganglion cell axons. Angle-closure glaucoma is characterized by narrowing or closure of the anterior chamber angle. The normal anterior chamber angle provides drainage for the aqueous humor (the fluid that fills the eyeball). When this drainage pathway is narrowed or closed, inadequate drainage leads to elevated intraocular pressure and damage to the optic nerve (figure 3). Acute angle-closure glaucoma occurs in eyes with a certain anatomical predisposition. It presents as a painful red eye and must be treated within 24 hours to prevent permanent blindness. (See "Angleclosure glaucoma".) Developmental glaucoma occurs in infants and children and is discussed elsewhere. (See "Overview of glaucoma in infants and children" and "Primary infantile glaucoma".) Both open-angle and angle-closure glaucoma can be divided into primary and secondary forms. Secondary glaucoma has many subtypes with elevated IOP resulting from uveitis, trauma, glucocorticoid therapy, vasoproliferative retinopathy, or ocular syndromes such as pigment dispersion or pseudoexfoliation (the deposition of white fluffy material within the anterior segment of the eye).

It is estimated that there are 44.7].8 million people with open-angle glaucoma in the United States (US) in 2010 [4]. including driving [6. and that the number will increase to 3. including benefits. One meta-analysis found no association between open-angle glaucoma and all-cause mortality [9]. Open-angle glaucoma is the most common type of glaucoma among populations of European or African descent.7 million people with open-angle glaucoma worldwide in 2010. the Early Manifest Glaucoma Trial followed 255 patients with a diagnosis of open-angle glaucoma over a mean of eight years. and reaches approximately 4 percent at age 80 [5].06-1. whereas angle-closure glaucoma is more common among populations of Asian descent [2]. and chronic).    . Mixed mechanism glaucoma refers to glaucoma with several etiologies (eg. Several earlyonset glaucoma syndromes are inherited as Mendelian dominant or recessive traits. openangle glaucoma complicated by superimposed angle-closure.2-fold for individuals with an affected sibling or parent. even when IOP was within the "normal" range of 8 to 22 mg Hg [25]. and elevated intraocular pressure [11. Elevated intraocular pressure (IOP) — There is a large body of literature illustrating the association between elevated IOP and both development and progression of open-angle glaucoma [19-24]. The ageadjusted rate of blindness from glaucoma among blacks was 6. The prevalence of open-angle glaucoma is below 1 percent in individuals under 55 years of age. Race — Race is an important risk factor for development and progression of open-angle glaucoma. mean IOP was a significant risk factor for progression of glaucoma (HR 1. black race. Family history — Family history is a significant risk factor for open-angle glaucoma in several population studies [16-19]. As an example. and health expenses [10]. It is estimated that there are 2. has a complex inheritance pattern. acute. open-angle glaucoma. family history. The estimated prevalence of open-angle glaucoma is approximately three times higher in blacks. Patients with open-angle glaucoma report decreased quality-of-life and difficulties with daily functioning. In the US. particularly in patients of Caucasian and African ancestry [13-15]. 95% CI 1. approaches 2 percent at age 65.and 2. however. respectively [16]. subacute.17). the cost of glaucoma to society has been estimated to be about $1.6 times that among whites. Patients with glaucoma are also more likely to report falls and motor vehicle collisions [8].6 million in 2020 [4]. and that this number will increase to 58.  Glaucoma can also be categorized based on timing (ie.  Age — The incidence of open-angle glaucoma increases with age. lost tax revenues.5 billion per year. with the likelihood that multiple genes interact with environmental factors [17]. Risk factors — The major risk factors for developing open-angle glaucoma include age.11. with blindness beginning 10 years earlier in blacks [3].12]. compared to whites [5]. or open-angle glaucoma with superimposed uveitis).7. The Baltimore Eye Survey found that the relative risk of open-angle glaucoma increased 3. EPIDEMIOLOGY — Glaucoma is the second leading cause of blindness in the world (after cataracts) [2] and the leading cause of blindness among African-Americans [3]. The rate of blindness from open-angle glaucoma also increases with age [3].4 million in 2020 [5].

While a small proportion of open-angle glaucoma in the US may be classified as normal tension. PATHOGENESIS — The pathogenesis of primary open-angle glaucoma is not clear. although high pressure is clearly associated with open-angle glaucoma. (See"Angle-closure glaucoma". Even in patients with documented findings of glaucoma on comprehensive eye examination (eg. These patients constitute a subgroup commonly referred to as low-tension or normal-tension glaucoma. diabetes mellitus. systemic hypertension. Central visual field loss is a late manifestation of open-angle glaucoma. Optic nerve axon loss may be related to ganglion cell susceptibility. the majority of patients with open-angle glaucoma in Asia have normal tension glaucoma [27]. and corneal edema. open-angle glaucoma is generally detected incidentally during comprehensive ophthalmic examination.21].) High elevations of intraocular pressure (IOP). cardiovascular disease. Although risk factors for the development of open-angle glaucoma have been welldocumented. Other factors — Other possible risk factors for developing open-angle glaucoma include myopia. MYOC mutations alter the myocilin protein. usually preceded by ganglion cell loss and optic nerve damage. low diastolic perfusion pressure. Thus. or to anatomic or physiologic features of the trabecular meshwork and other outflow structures. In contrast.37]. pain. section on 'Clinical presentation'. Some patients are unaware of field loss even when it has progressed to . microcirculatory deficiency at the optic nerve head. optic disc changes). Myocilin is produced in the ciliary body and trabecular meshwork. many patients with elevated pressures never develop the optic nerve and field changes characteristic of glaucoma [20. It is not clear if elevated IOP is caused by factors related to aqueous production. redness. it is unclear which patients go on to develop loss of visual acuity and blindness [36]. risk factors for progression of open-angle glaucoma have not been as conclusively established [35]. or visual symptoms. Myocilin-associated glaucoma is characterized by elevated IOP. with IOP >40 mmHg in some patients with juvenile open-angle glaucoma. aqueous outflow. conjunctival erythema.24]. visual field deficits. Results conflict whether fluctuation in IOP is predictive of glaucoma progression [23. variation in axon susceptibility might explain why the disease state does not correlate well with elevated IOP [38]. a rare autosomal dominant condition with glaucoma onset between 3 and 40 years of age [11]. pseudoexfoliation. generally cause no pain. it is neither necessary nor sufficient for the diagnosis and is therefore termed a "risk factor" for the condition. This is in contrast to angle-closure glaucoma in which patients present with symptoms and signs including loss of visual acuity. These factors may play a combined role: circulatory or extracellular matrix factors could account for both high pressures and axon loss. Mutations in the myocilin gene (MYOC) have been identified in about 4 percent of adults with open-angle glaucoma and more than 10 percent of cases of juvenile open-angle glaucoma. Approximately one-sixth of patients in the US with otherwise characteristic openangle glaucoma will have a consistently normal IOP [26]. CLINICAL PRESENTATION — Individuals with open-angle glaucoma rarely experience symptoms. up to 40 mmHg in patients with openangle glaucoma. or extracellular matrix factors [11. but its precise role in regulating intraocular pressure is unknown. Thus. and hypothyroidism [28-34]. There is no loss of visual acuity as long as central vision is preserved.

95% CI 0. 95% CI 0. the harms and benefits associated with early detection.603 Euros per one year of avoided visual disability) and quality-adjusted life years (9. but that screening in older or other higher risk populations might be cost-effective [47].023 Euros per one QALY gained by screening) [48].36. with more recent studies using Markov modelling [45-48].56) and the perhaps more clinically important outcome of visual field abnormalities (HR 0. partly since no randomized trials have evaluated screening strategies for the prevention of open-angle glaucoma [49]. Since the prevalence of elevated IOP in the general population is approximately 4 percent among individuals age ≥40 years [44] and 12 patients would be needed to treat to prevent one case of glaucoma. no diagnostic test has ideal sensitivity or specificity for screening in the general population.27-0. as mentioned below. Cost-effectiveness — In the absence of randomized trials assessing screening strategies.23-0. and additional testing) [45. There is a great deal of uncertainty in the assumptions of these models. and with what frequency. One study in the United Kingdom found that neither IOP measurement alone nor comprehensive eye examination were cost-effective in subjects age ≥40 years. and intraocular pressure measurement in persons age 50 to 89 was costeffective for preventing visual disability (32. However. 300 individuals would need to be screened to prevent one case of glaucoma within five years of treatment.  The American Academy of Ophthalmology (AAO) recommends a comprehensive eye examination for every patient over age 40 by an ophthalmologist or an optometrist skilled in the assessment of the optic nerve and knowledgeable about . alone or in combination [40]. and the thresholds for different treatments in relation to cost (determining follow-up. visual field testing. adherence. Another study in Finland found that screening with combined fundus examination. SCREENING — Intraocular pressure (IOP) testing remains the most available and best studied means of screening for glaucoma.48]. The study further estimated that 12 subjects with elevated IOP would need to be treated to prevent one case of glaucoma within five years of treatment. it is important to note that the median progression rate is much slower (approximately 70 years).56. several studies have attempted to determine the cost-effectiveness of glaucoma screening.central "tunnel vision" of 10 to 20 degrees. The mean progression rate from a full field of vision to blindness takes approximately 25 years in untreated patients [39]. One large randomized trial (n = 1636) found that IOP lowering medication reduced the risk of both optic disc deterioration (HR 0. those randomly assigned to topical IOP lowering medication were less likely to develop open-angle glaucoma compared to those randomly assigned to placebo (HR 0.81) [41]. However.76) [43]. Visual field loss cannot be recovered once it has occurred. what screening tests should be performed.) Evidence for treating elevated intraocular pressure — Randomized trials that investigated the effect of lowering IOP in patients with elevated IOP without visual defects have found some benefit in delaying or preventing the onset of open-angle glaucoma [41. In a meta-analysis of five randomized trials in adults with elevated IOP (n = 2318).39-0. Recommendations of others — There is significant variation in screening recommendations from different organizations. (See 'Diagnosis' below. It remains controversial which populations should be screened.45. since only a small minority of patients progress rapidly to blindness.42]. 95% CI 0. particularly with regard to which is the optimal screening protocol.47.

the presence of characteristic abnormalities in the visual field (eg. Referral of high-risk individuals to a specialist was deemed "clinically prudent" [51]. Adult onset. typically in the presence of elevated intraocular pressures. and that early open angle glaucoma is asymptomatic. Field testing is performed by the ophthalmologist once the patient falls into the diagnostic category of "glaucoma suspect" based upon the other risk factors. nasal step paracentral scotoma. cupping. black race. generalized depression) in the absence of other causes or explanations for a field defect. they also felt that the evidence was insufficient to determine the extent to which screening would reduce impairment in visionrelated function or quality of life. Earlier screening may be appropriate for individuals with significant risk factors for glaucoma. arcuate defect. and that early treatment reduces the development and progression of visual field defects. The Canadian Task Force on the Periodic Health Examination also concluded that there was insufficient evidence to recommend for or against screening for glaucoma in the periodic health examination.glaucoma [26]. After age 60. The AAO also suggests periodic examination for black men and women between ages 20 to 39. Screening only by measuring IOP is not appropriate since a substantial number of patients with glaucomatous visual field changes have normal IOP [20]. progressive change. While they felt there was good evidence that screening could detect increased IOP and early open-angle glaucoma. The American Academy of Ophthalmology (AAO) Preferred Practice Pattern defines primary open-angle glaucoma as a chronic. cupping. Some authorities consider either characteristic optic nerve change OR visual field defects as sufficient criteria for diagnosis of open-angle glaucoma [55. Although the randomized trials cited in this section performed IOP-based screening only. They noted that harms associated with treatment for increased IOP and early open-angle glaucoma include local eye irritation and an increased risk for cataracts. we suggest screening with a comprehensive eye examination since individual tests such as fundus examination or measurement of intraocular pressure alone will likely fail to detect many cases of glaucoma [52-54]. A typical frequency for repeat evaluation for individuals between ages 40 and 60 is every three to five years for those without risk factors. the effectiveness of treatment. we suggest that individuals over age 40 be screened for glaucoma. or notching of the disc rim. and every one to two years for those with one or more risk factors such as borderline pressures. a comprehensive eye examination should be performed every one to two years.) The US Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against screening adults for glaucoma [50]. and often asymmetrical disease.  . (See 'Risk factors' above. and family history. which is characterized (in at least one eye) by all of the following [26]:  Evidence of glaucomatous optic nerve damage from either or both of the following: the appearance of the disc or retinal nerve fiber layer (eg. nerve fiber layer defects).   Synthesis — Given the risk of blindness with untreated glaucoma.56]. generally bilateral. DIAGNOSIS — Glaucoma is diagnosed in patients with characteristic nerve damage on fundus examination (picture 1A-B) and visual field testing. thinning.

Although cupping has the highest sensitivity and specificity of any other finding on eye examination. There are several types of automated perimetry technologies. Reliable field testing requires comprehension and cooperation on the part of the patient. patients with elevated IOP should be referred to an ophthalmologist given their higher risk of open-angle glaucoma. although there is a role for careful manual perimetry in some cases. and nerve fiber layer defects. Diagnostic tests Fundus examination — The primary care clinician should be attentive to the presence of cupping seen in the fundus. Any patient with high IOP detected during community-based screening or spectacle/contact lens evaluation should also be referred for comprehensive eye examination. Who should be referred for comprehensive eye examination? — Patients with abnormal cupping should be referred for a comprehensive eye examination. (See 'Risk factors' above. However. Dementia and other mental or physical problems may preclude testing in certain individuals. and short wavelength automated perimetry [53]. Absence of known (eg. Other findings on fundus examination indicative of glaucoma include thinning or notching of the disc rim.  Open. Visual field testing — Open-angle glaucoma ideally should be diagnosed before there is significant visual field loss. 99 percent of eyes with an initial pressure <20 . normal appearing anterior chamber angles. secondary) causes of open-angle glaucoma. Intraocular pressure — Elevated intraocular pressure (IOP) alone does not establish the diagnosis of open-angle glaucoma [26. In addition. over 90 percent of adults with pressures >21 mmHg have no optic nerve damage. One-third to one-half of individuals with glaucoma field defects have intraocular pressures ≤21 mmHg when first detected (normal IOP 8 to 21 mmHg) [60]. is not useful in the detection of glaucoma. Combining cupping with other diagnostic criteria increased diagnostic yield. Automated perimetry is an important diagnostic tool that is much more reliable at detecting visual field loss in glaucoma compared to confrontational field testing [58]. confrontational field testing. Automated perimetry has become the standard of care for optometric and ophthalmic practice in the detection and monitoring of glaucoma. However.) A prospective population study of risk factors associated with glaucomatous field loss found that during a period of five years. depending on user characteristics and the type of test being used. there is no single cutoff criteria that yields sufficiently high sensitivity and specificity to make cupping a useful diagnostic test [57]. using the examiner’s fingers.59]. Visual field testing can be time consuming and of variable specificity and sensitivity. One study found that ophthalmologists. using direct ophthalmoscopy. particularly in patients with advanced field loss or dementia. forcing the clinician to rely upon other variables in diagnostic and therapeutic decision-making. A cup whose diameter is greater than 50 percent of the vertical disc diameter is indicative of glaucoma. detected less than one-half of cases of glaucoma [52]. including standard threshold automated perimetry. Cupping describes a hollowed-out appearance of the optic nerve or "disc" on fundus examination. progressive change of the size or shape of the cup. frequency doubling technology perimetry.

pneumotonometry. a patient with an IOP of 28 and advanced open-angle glaucoma including field loss and cupping may represent an emergency because of risk of imminent field loss. falsely higher measurements occur in patients with thicker corneas and falsely lower measurements in those with thinner corneas [62]. Pachymetry — Pachymetry is the measurement of corneal thickness. it is less common for primary care providers to measure IOP. As an example. The clinical implications of these findings require further study.mmHg continued to be free of glaucomatous field defects. Due to the effects of central corneal thickness on the mechanics of applanation tonometry. while a patient with a healthy nerve could withstand an IOP at that level for weeks with little risk of further nerve damage. Pressure parameters for referral — There are no standard criteria for referral to an ophthalmologist for patients with elevated pressures. The sensitivity for the diagnosis of openangle glaucoma by IOP measurement was 47. Regardless. or air-puff tonometry. Generalists who practice in populations that do not have access to optometric or ophthalmic care can learn Schiotz tonometry and use it in conjunction with the optic disc examination in deciding whom to treat or refer. and thus fall out of the realm of the primary care clinician.1 percent and the specificity over 90 percent at an IOP cutoff point of >21 mmHg [54]. There was no cutoff value for IOP that had reasonable sensitivity and specificity as a screening tool for the diagnosis of open-angle glaucoma. There is some evidence that wearing a tight necktie may temporarily increase IOP [63]. compared with 93 percent of eyes with an initial pressure ≥20 mmHg [61]. which is more common among patients with angleclosure glaucoma or secondary (rather than primary) open-angle glaucoma. All tonometry methods require specialized equipment and skill. it can be performed by ultrasound or other methods. it is prudent to ask patients to loosen collars and ties prior to measuring IOP. and should be interpreted in the context of patient history and examination findings. Primary open-angle glaucoma rarely presents with IOP >30mmHg. Applanation tonometry is a method that determines the intraocular pressure from the force required to flatten (applanate) a constant area of the cornea (picture 2). (see "Angleclosure glaucoma" and "Evaluation of the red eye").) Schiotz tonometry is a handheld device that is relatively inexpensive. Applanation tonometry is most accurate and less subject to artifact.5) increased the sensitivity to 61 percent but decreased the specificity to 84 percent. The presence of either increased IOP (>21 mmHg) or increased vertical cup/disc ratio (≥0. but requires frequent use for reliable results. Ophthalmologists and optometrists can measure IOP by applanation tonometry. (See 'Pachymetry' below. Patients with thin corneas are at higher risk . The following represent indications for ophthalmologic referral based on clinical practice experience:     IOP >40 mmHg: Emergency referral IOP 30 to 40 mmHg: Urgent referral (within 24 hours) if no symptoms suggesting acute glaucoma IOP 25 to 29 mmHg: Evaluation within one week IOP 23-24 mmHg warrants repeat measurement to confirm and/or referral for comprehensive eye examination These indications are not absolute. In developed countries. This can be partially corrected with pachymetry.

as well as other eye diseases. and conventional qualitative assessment of stereoscopic photographs of the optic disc [68]. These articles are best for patients who want a general overview and who prefer short. (see 'Intraocular pressure' above). and they answer the four or five key questions a patient might have about a given condition.)  Basics topics (see "Patient information: Age-related vision loss (The Basics)" and "Patient information: Glaucoma (The Basics)") SUMMARY AND RECOMMENDATIONS  Open-angle glaucoma is an optic neuropathy characterized by progressive peripheral visual field loss followed by central field loss. corneal thickness affects the results of applanation tonometry. (See 'Classification' above.” The Basics patient education pieces are written in plain language. and scanning laser polarimetry are non-invasive imaging techniques that analyze light reflected off the fundus [66. and elevated intraocular pressure. perhaps in part related to increased aqueous production and decreased outflow (figure 2). (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest. scanning laser polarimetry.for the development of open-angle glaucoma [43.)  . Newer technologies for fundus evaluation — Several newer technologies have been developed to evaluate the optic disc and retinal nerve fiber layer. Here are the patient education articles that are relevant to this topic. The devices generate a digital image and quantification of specific features of optic nerve head anatomy. We encourage you to print or e-mail these topics to your patients. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. but not better than. HRT. Beyond the Basics patient education pieces are longer. This is usually but not always in the presence of elevated intraocular pressure (IOP). INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials. These may aid in the early detection of glaucoma. One study compared OCT. Accuracy of results from stereoscopic images is dependent on the experience and skill of the interpreter. Additionally. “The Basics” and “Beyond the Basics. stereoscopic photographs. These tests are well-tolerated by patients. Heidelberg retinal tomography (HRT). in a characteristic pattern. Ophthalmologists may perform pachymetry in patients with suspected or diagnosed open-angle glaucoma to further evaluate their risk for development or progression of open-angle glaucoma [65]. and pachymetry may adjust for this effect. (See 'Epidemiology' above. family history. black race.) Open-angle glaucoma is a leading cause of irreversible blindness in the world. more sophisticated. whereas the newer technologies provide more quantitative data that is less user dependent. easy-to-read materials. The major risk factors for developing open-angle glaucoma include age.64]. The three newer technologies performed as well as. at the 5th to 6th grade reading level. and more detailed.67]. The need for pupil dilation varies with the particular device and the part of the fundus being studied. Optical coherence tomography (OCT).

363:1711. et al. Br J Ophthalmol 2006. Ophthalmology 2007. we suggest performing a comprehensive eye examination rather than screening with individual tests (eg. typically in the presence of elevated intraocular pressures. (See 'Screening' above. Some authorities consider either characteristic optic nerve change OR visual field defects as sufficient criteria for diagnosis of open-angle glaucoma. McCarty CA. 360:1113. Sommer A. 3. risk factors for the progression of open-angle glaucoma. 17. 126:1030. Leblanc RP. (See 'Clinical presentation' above. Lankaranian D. 90:262. Primary open-angle glaucoma.) We suggest that all individuals over age 40 be screened for glaucoma (Grade 2B). 117:1705. Relationships in glaucoma patients between standard vision tests. 125:30. Akbari S. et al. Wiggs JL. open-angle glaucoma is generally detected incidentally on comprehensive ophthalmic examination. Earlier screening may be appropriate for individuals with significant risk factors for glaucoma. Eke T. 12. Five-year incidence of open-angle glaucoma: the visual impairment project. 21:604. Risk of falls and motor vehicle collisions in glaucoma. Ophthalmology 2010." Thus. Lifetime visual prognosis for patients with primary open-angle glaucoma. Chauhan BC. N Engl J Med 2009. et al. 10. Am Fam Physician 2003. Leske MC. Racial differences in the cause-specific prevalence of blindness in east Baltimore. Some patients are unaware of field loss even when it has progressed to central "tunnel vision. Ophthalmic Epidemiol 2010. Tielsch JM. 127:204.    Individuals with open-angle glaucoma rarely experience symptoms. et al. 5. Katz J. 16. 8. 4. Ang GS. Wolfs RC. 7. Kwon YH. Quigley HA. Glaucoma is second leading cause of blindness globally. 325:1412. Akbari M. Czudowska MA. Genetic etiologies of glaucoma. The Baltimore Eye Survey. et al. 114:1965. 15. Arch Ophthalmol 2004. 6. Lorenzana LL. Pasquale LR. 109:1047. et al. 2. 14. Friedman DS. Richman J. Broman AT. Wolfs RC. Tielsch JM. 82:887. Predictors of long-term progression in the early manifest glaucoma trial. Katz J. 17:144. 67:1937. Haymes SA. Distelhorst JS. Hughes GM. The number of people with glaucoma worldwide in 2010 and 2020. Sommer A. Weinreb RN. 112:69. Arch Ophthalmol 1994. 122:532. Hyman L. Bull World Health Organ 2004. Primary open-angle glaucoma. et al. 11. et al. Arch Ophthalmol 2007. 48:1149. Canadian Glaucoma Study: 2. Nicolela MT. Ophthalmology 2002. Mukesh BN. . Open-angle glaucoma. (See 'Who should be referred for comprehensive eye examination?' above. and ability to perform daily activities. If the decision is made to undergo screening. Incidence of glaucomatous visual field loss: a ten-year follow-up from the Rotterdam Study.) Glaucoma is diagnosed in patients with characteristic nerve damage on fundus examination and on visual field testing (picture 1A-B). 13. Mikelberg FS. Kuehn MH. Rait JL. Fingert JH. Taylor HR. Alward WL.) Use of UpToDate is subject to the Subscription and License Agreement. Prevalence of open-angle glaucoma among adults in the United States. fundus examination or measurement or intraocular pressure alone) (Grade 2C). Invest Ophthalmol Vis Sci 2007. Lancet 2004. Ramdas WD. Arch Ophthalmol 2008. Family history and risk of primary open angle glaucoma. Arch Ophthalmol 2009. Khaw PT. Balaszi AG. REFERENCES 1. Eye (Lond) 2007. (See 'Diagnosis' above.) Patients with abnormal cupping on fundus examination should be referred for a comprehensive eye examination. N Engl J Med 1991. 9. O'Colmain BJ. Kingman S. The association of primary open-angle glaucoma with mortality: a meta-analysis of observational studies. Heijl A. quality of life.

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