Glaucoma screening in the health care setting

SURVEY OF OPHTHALMOLOGY

VOLUME 28 - NUMBER 3 - NOVEMBER-DECEMBER

Glaucoma Screening

in the Health Care Setting

LEAH LEVI, M.B., B.S., AND BERNARD

Department of Ophthalmology, Massachusetts

1983

New England

SCHWARTZ,

Medical

M.D., PH.D.

Center and Tufts University School of Medicine,

Boston,

Abstract. Glaucoma surveys are an important means of detecting early cases of glaucoma. Traditionally, most such surveys have been conducted in the community, while the health care setting has been underutilized as a screening location. We reviewed studies on surveys conducted in community and health care settings, using tonometry and ophthalmoscopy, and presented data from a study we carried out in the outpatient department ofa hospital. Results ofour retie\+ indicate that over 11 times as many people were screened in the community studies as in the health care studies, but the latter had the higher percentage ofreferrals. Data from the literature review, as well as from our own study, suggest that the high number of referrals is related to the characteristics of the population available for screening in a health care facility. In such a population there is a higher percentage of individuals at risk for development of glaucoma. Risk factors for the disease include age, sex (males more at risk than females), race, (blacks more at risk than whites), family history ofglaucoma, and presence ofdiabetes and vascular diseases. It was also found that ophthalmoscopy is an elIective, but underutilized, method of screening. U’e recommend an increase in use of health care facilities as sites ofglaucoma screening surveys. LVe also suggest that physicians employ ophthalmoscopy to screen for glaucoma as part ofthe routine funduscopic examination. (Surv Ophthalmol 28: 164-t 74, 1983)

Key words. screening

l

community tonometry

surveys

l

glaucoma

T

health

care facilities

l

ophthalmoscopy

l

mize the yield of a glaucoma detection program. In addition, patient follow-up and compliance are more likely, since the patient has usually already established a relationship with the health care facility. Finally, in the health care setting, the patient’s physician represents a largely untapped resource for glaucoma screening. The purpose of this paper is to review the literature on glaucoma screening in the community and in a health care setting. In addition, we will present data on a screening study we performed in a hospital outpatient department and give recommendations regarding such a screening program. We will not discuss the use of visual fields for screening since this is covered in another paper in this volume.“’

he course of glaucoma is an insidious one and in most cases remains asymptomatic until the visual field has been seriously diminished. Consequently, it is a disease suited to a preventive approach, and this has been underlined by the large number of glaucoma screening studies published since one of the earliest such reports in 1951.” Most commonly, glaucoma screening has taken place in the community at health fairs and glaucoma days sponsored by service organizations and places of employment. Most of these screening programs have been aimed at detecting early cases of glaucoma and obtaining some information about the prevalence of the disease. This approach has also been important in trying to increase community awareness of glaucoma. Another appropriate site for glaucoma screening is a health care setting, e.g., physician’s office, multiphasic health screening facility, employee health clinic and hospital outpatient department. It has been shown that the detection percentage for glaucoma is higher in a hospital outpatient population than in a normal population.““.7” Since screening in these settings tests high risk groups,” it helps maxi-

Screening in the Health Care Setting Versus in the Community OVERVIEW Table 1 describes a number of screening studies carried out between 1951 and the present. All of the studies used tonometry as a major screening tool, although several used ophthalmoscopy al164

GLAUCOMA 1 i’!

l~l.i.l~~.ii

SCREENING

IN THE

HEALTH

CARE

:il.Oi.il

The studies reviewed were chosen because all stated their referral results, or contained sufficient data to enable these percentages to be calculated. These surveys could be divided into those that tested essentially healthy people in the communit): and those that took place in an ambulatory hralth care setting. Data from these studies were analyzed statisticall), by the test to compare proportions which uses the normal approximation to the binomial distribution.” In the 24 community-hasrd studies reviewed, a total 01‘418,338 subjects were screened; 22,.560 were judged to need further evaluation, a referral percentage ot‘5.41% (Table 1A). The 16 studies based in health care settings screened 36,692 subjects and refisrrcd 2.99.5 or 8.16% (Fig. 1 and Table 1B). As ~~11 as showing a higher rcfi,rral rate in the health care setting, these tigurcs rc\,eal that over 11 times LS man)’ people have been scrcencd fi)r glaucoma in the communit), as b), studies in the health care contest. ‘I’his is probably an underestimation, since community glaucoma surveys, which screen a large number ofpeople. are not necessarily reported. It is e\.iclent that the health care setting is underutilized in glaucoma screening. Included in the stndies re\Gewed for the health care setting is a sur\q. we conducted in the general medical outpatient department at New England I\Iedical (:entc.r, Boston. After being trained in the use ol‘thc American Optical noncontact tonometer”” it1 Ad tllc recognition ot suspicious optic discs,‘;_“l_“‘,‘l /,1,/,)one ofus (I,.L.). a nonophthalmologist pli) sician, screened medical outpatients ti)r ,qiaucoma afirr dctcrmining \&al acuity. Ophthalmoscop~- through undilatcd pupils was alwa)x filllowed by tonomctr!‘. The age, sex and race of‘ the patient were noted, as well as the time of’ day.“.” The patient’s medical problems were recorded, particularly tht, prcsenccb of diabetes mellitus or LWCLIlar disease (taken to include vascular hypertension, atherosclerotic heart disease or cercbrovascular disease). .-\ note was also made of whether the subject had a first-degree relative with glaucoma. lntraocular prcssurt* was mcasurrd by noncontact tonometry. Keferral critrria were: 1) intraocular pressure of‘ 3 24 mm Hg, and 2) asvmmetry (difference in pressure brtwcen eyes) 3 .?Imm Hg. Referral rriteria f?)r optic disc appearance were: I) area of‘pallor 3 30%: 2) asynimetr! 3 10% area of pallor:“’ :5) \.rrtical bias ofpallor; 4) notching ofrim; and 5) disc hemorrhage. 01‘ ‘770 individuals screened, 102 were referred, reprcscn~in~ a reKerra1 percentage of 13.2%. The composition of’ the total population with regard to xi. racr, age, medical status and family histor). of glaucoma can hc srcn in Table 2. This table also so.

165

SETTING

Authors Brav and Kirber, 1951”’ Wolpaw & Sherman, 1954”” Power, 1957”’ Rlitls. 1959”’ Gra!,, 1961) “’ Taubenhaus, t961”’ Garner & Dressier. 1961” I\rmaly, 1962’ Stromberg, 1962” Packer et at. 1964” Perkins. 1965”’ Blumenthal 8r Kornbleuth, 1965” Hollows & Graham, 1966” Fr)dman et at. t9662’ \Vatkrr (cr Vodden, 1966”’ Hankrs, 1968’ Norsko\.. 1970” Kahn et al, 19771; Hechetoille et at, 1980 Brll~tsson. 1980’“~’ Klein & Klein, 1981’? Dorni~~lct <‘t at. 1981?’ Shiest et al, I!llll” (Zoopcr et al. 1982”’

Referred*

Number screened

%

10,000 12,803 3.986 “..S9 21,197 :1.018 1,451 4,628 7.275 3.505+ I.OO(l “.200 .+,23t

3.2 12.8 4.9 6.8 5.2 6.5 7.5 12.7 4.5 2.7 9.8 5.3 Il.8 2.7 7.0

67.193 t5.!Wit .5,94t

“,(X31 2,477 ,189 I,.51 I

1I .!I 2.7 27.0 18.-t

5,351 “27;178 11.iiT,O 398

(11) (324)

( 1,635) (196) (173) (I.1 12) (196)

(IOY) (589) (325) i!G) (98) (117) (198) (1,793) (1,122) (708) (55) (668) (90) (313)

20.7 3.3 1185) 5.2 I I 1,783) 3. I (:m) 4.5 (181

R&-red* .\uthors

screened

3.5 25.!J to.7 *.:!I 6.0 3.9 8.1 28.8 3.8 5 i

8.8 t3.5 2.6 I 5,3 13.2

Spector et at, t97ji’ Robertson, 1977”’ Steinmuin‘ et al, 1982” Levi Ik Schwartz. 1983 TOTAL

% 6.0

Zelter & C:hristensen. 1954x’ l’aughan et at, 1957”’ Horslt-sv et at, 1958” Lask> & al. 1959” Bendor-Samuel, 1960” Im1tz et at 1963”’ Packer et ai. t964jt’ hlcDonald Pr Johnsos. 1965”’ \Valkrr & \‘odden. 1966” Norskov. t967jr Ross, 19G8”’ F.tir L . l<)7‘]!” _

36,692

*For studies in which referral percentages valurs were calculated from the authors’ tljutxet of larger Survev.

8.011

(n)

(60) (85) (313)

(IOS) (217) (120) (‘21) (822) (372) (I”)

(9.5) (211) (IIN) i 12) 186)

( I mq (2,935)

were not stated, data.

166

Surv Ophthalmol

shows the referral the population. REFERRAL FINDINGS

28(3) November-December

percentages

for subgroups

PERCENTAGES

FOR

1983

LEVI, SCHWARTZ

within

SPECIFIC

The referral percentages for 20 glaucoma screening surveys are presented in Table 3. Thirteen of these, including our study, were performed whol1 4.33.35.43.72.74 or partly56.62.78 in a hospital outpatient Y setting, or in a private practice.26.4g.6” The remaining studies were community-based and chosen because, like our study, they included ophthalmoscopy as In all procedure. 4.5,10%19,34.37,71 part of the screening studies referral percentages were stated or could be calculated from the data.

1 Fn

Type of SUfWy (Table 1)

Intraocular Pressure Table 4 presents the referral percentages for intraocular pressure and optic discs in our study. A total of 4.6% had abnormal intraocular pressure on screening: 2.5% with only abnormal pressure and 2.1% with a combination of abnormal intraocular pressure and abnormal discs. These percentages were fairly constant throughout the study, indicating that we had seen a representative sample of our medical population (Fig. 2). These referral percentages for ocular pressure are at the lower range of values found in the studies reviewed in Table 3 and

SW (Table61

Age (Table 5)

RPCe (Toble71

Family History (Table61

Vascular Disease (Table 91

Fig. 1. factors. studies all data

Comparison of referral percentages for various Each set of bars represents composite data from listed in the tables cited below the bars. Since not

should

not be compared

values

shown

tests

in the histogram above

to compare

are from the same studies, among

bars

different

represent

results

proportions.‘X

Levi and Schwartz,

1983 % (no.)

referred

Overall

IOP

only Discs

only

IOP t discs

No. Total Sex

Group

population

Race Age

Medical

status

Family history glaucoma

composition

P

of statistical

TABLE 2

division

values

sets of bars.

resemble the results from community surveys, which have a lower referral percentage than surveys in the health care setting (also see Table IA). The low percentage of referrals in our study may be attributable in part to sampling variations: for exam-

Overview of Results from

Group

Diabetes Mellitus (Table 10)

screened

All those screened Male Female White Black < 40 40-59 3 60 Vascular** disease No vascular disease Diabetes mellitus No diabetes mellitus Neither vascular disease nor diabetes mellitus

770 239 531 671 94 170 273 327 422 348 75 695

13.2 (102) (40) 16.7 (62) 1.7 (83) 12.4 (18) 19.1 (16) 9.4 (40) 14.7 (46) 14.1 (61) 14.5 (41) 11.8 (12) 16.0 (90) 12.9

2.5 3.8 1.9 2.5 2.1 0.0 2.2 4.0 3.1 1.7 4.0 2.3

(19) (9) (10) (17) (2) (0) (6) (13) (13) (6) (3) (16)

8.7 10.9 7.7 7.8 14.9 8.2 9.2 8.6 8.5 8.9 8.0 8.8

(67) (26) (41) (52) (14) (14) (25) (28) (36) (31) (6) (61)

2.1 2.1 2.1 2.1 2.1 1.2 3.3 1.5 2.8 1.1 4.0 1.9

(16) (5) (11) (14) (2) (2) (9) (5) (12) (4) (3) (13)

314

12.4

(39)

1.6

(5)

9.6

(30)

1.3

(4)

Yest No

55 715

20.0 12.7

(11) (91)

5.5 2.2

(3) (16)

12.7 8.4

(7) (60)

1.8 (1) 2.1 (15)

of

*Includes only patients with a combination of ocular pressure and disc abnormalities. **Includes vascular hypertension, atherosclerotic heart disease and cerebrovascular disease. tFirst-degree relative (parent, child or sibling) with glaucoma.

GLAUCOMA

SCREENING

IN THE HEALTH

167

CARE SETTING

in contrast to most of the cited studies, which excluded subjects aged under 40 years, almost 25% of our population was in this age group. In addition, our referral level of intraocular pressure was 24 mm Hg, compared to the more sensitive lower values used in about half the cited studies. Lastly, we used (NCT). Some autonometer a noncontact thorsL’.“‘.7n.7’have suggested that the NCT may underestimate intraocular pressure particularly at lower levels. In fact, Shiose recommends that a level of 18 mm Hg be regarded as borderline.‘” Our referral level may have given us a relatively high false negative rate. These figures nonetheless illustrate the higher referral percentage for abnormal intraocular pressure in studies conducted in a health care setting. (P < 0.0001). ple,

Abnormal Discs The studies listed in Table 3 are a subset chosen because referral percentages were available or could he calculated. Only nine used ophthalmoscopy at screening. Five of the nine studies used quantitative criteria for ophthalmoscopic evaluation, but only one of those five was based in a health care setting. In this study by Hammond and Begley,” 8% of those screened were referred for an abnormal disc, which is comparable to our results and significantly higher than the 3.9% value calculated from composite figures for the four community-based surveys (Table 4) (P < 0.01). In our population 10.8% had abnormal optic discs on screening: 8.7% with this finding alone, and 2.1% who also had abnormal intraocular pressure. These figures suggest a higher percentage of referrals for optic disc abnormalities in a health care setting than in community surveys, but this could be due to different criteria for referral. Additionally, Tables 3 and 4 point out the underutilization of ophthalmoscopy as a screening tool. Particularly in outpatient settings, it is well known that physicians are reluctant, even when trained, to use tonometry Since regularly. l”.;?ti’L.7?.il.H.~ they

are

familiar

with

ophthalmoscopy and the criteria for glaucomatous discs have recently become more defined,:l’l.“.‘i’X’ ophthalmoscopy could become a widespread and inexpensive method for glaucoma screening. Co-occurrence of Abnormalities Pressure and Discs

in Intraocular

On screening, 2.1% of our population had both abnormal intraocular pressure and abnormal discs. Only four other studies, all done in the communitvI 1‘.i.L’l~‘.i’ mentioned a referral percentage for both abnormalities occurring in the same person, so comparison is difficult. However, it appears that the number of people one can expect to find with both

E 8

5.0 -

h 0

L loo

200

300 Number

4w

of Patients

500

600

700

800

Screened

2. Cumulative referral percentages for Levi and Schwartz, 1983. Note that the percentages become relatively constant at approximately 400 patients screened for total of all criteria; and at about 300 patients screened for abnormalities in discs alone, intraocular pressure alone, and the combination of discs and pressure. Fig.

abnormalities is low (Table 3). This suggests that use of either screening method alone would result in a high percentage of false negatives.

Glaucoma

Screening Surveys Factors

and Risk

AGE The incidence of ocular hypertension and glaucoma increases with age, t.ll.‘~t.97.ns.t2.t7.67 and the susceptibility of the optic nerve to damage increases with age at all pressure levels.’ Table 5 shows referral percentages for different age groups in glaucoma screening studies. It can be seen from the composite figures that the percentage of referrals does increase significantly with age (also see Fig. 1). This is also seen in our study, with the overall referral percentage increasing up to the 4059 age group, with no further increase in the 60 and over age group. Table 2 shows, however, that the referral percentage for intraocular pressure alone increases through all three age groups, with no subjects under 40 being referred for this abnormality, in contrast to 4.0% of those 60 years or older. However, the referral percentage for optic discs only shows no increase with age. SEX Table 6 shows glaucoma screening studies which gave referral data according to sex. Four of these, including the Framingham Study and our study, show a higher percentage ofreferrals for males than females. The composite figures in ths table show that this higher referral rate is significant (P = 0.0054; see also Fig. 1).

168

Surv Ophthalmol

28(3) November-December

1983

LEVI,

SCHWARTZ

TABLE 3A Referral

Percentages for Specijk

Abnormalities

in Communi<~ Surveys Referral

Criteria YO

No.

Authors

IOP

Hollows & Graham, 1966”$

G b 21 mmHg

Bankes et al, 1968”

G >21

Kahn et al, 19771s7

mmHg

Bechetoille

et al, 1980’

G > 24 mmHg** asymm. > 3 mmHg G > 23 mmHg

Bengtsson

1980”‘”

G > 20.5 mmHg

Shiose et al, 19817’

NCT > 18 mmHg G > 20 mmHg

Cvoper

et al,

1982”’

S >

21 mmHg

Discs “Excessive excavation” (using graticule) “Suspicious discs” C/D 2 0.5 asymm. 2 0.2 C/D > 0.4 or 0.3 if vertical bias; asymm. > 0.2 Enlarged cup notching vertical bias hemorrhage Area pallor > 36% Notching hemorrhage CID > 0.5 asymm. > 0.1

Other

Family history Haloes Field defect

Field defect

Nerlre fiber bundle defect

Arden grating

referred*

Discs & IOP

screened

IOP

discs

4,231

8.6

2.2

-

5,941

6.3

2.0

0.1

2,445(1OP) 2,347(disc)

3.6

12.8

-

489

1.8

11.2

5.3

1,511

6.2

5.7

1.6

11,660

1.6

1.5

0.1

398

1.5

3.0

;\bbreviations: S = Schiotz tonometer; MM = McKay Marg tonometer; NCT = non-contact tonometer; G = Goldmann applanation tonometer. *For studies in which referral percentages were not stated, values were calculated from authors’ data. **Actual IOP criteria differed, but referral rate at b 24 mmHg ahle to he calculated from data for comparison purposes.

RACE The prevalence of glaucoma is higher in blacks than in whites, and its severity appears to be greater at a given age for blacks than for whites. 21l.L’I.?7.t”.t7.i(I.HI) Table 7 shows studies which gave referral rates according to race. The composite figures demonstrate that blacks are referred more often than whites for suspicious findings at glaucoma screening (I’ < 0.0001; also see Fig. 1). This agrees with our study, in which 19.1% of blacks were referred compared to 12.4% of whites. In particular, blacks were referred for suspect discs almost twice as frequently as whites (Table 2). FIRST-DEGREE

RELATIVE

WITH

GLAUCOMA

Family members (parents, children and siblings) ofpatients with glaucoma are at higher risk ofdeveloping the disease than those without such a family his~ory~l~.i’_“.~7.‘7.“0

Table 8 shows several glaucoma screening/detection studies which concentrated on examining firstdegree relatives of glaucoma patients. Their results are compared to the composite figures for the studies cited in Table 1. Although these latter studies no doubt contain some subjects who do have a family history of glaucoma, the comparison is still illustra-

tive; whereas an average of20.41% of those tested in family studies were either referred or found to have glaucoma, the “non-family” studies had a referral percentage of5.57% (P < 0.0001, also Fig. 1). Our own study also illustrates this trend, with an overall referral percentage of 20.0% for those with a lirstdegree relative with glaucoma, compared to 12.7% of those without such a family history. This is most noticeable in the percentage of referrals for intraocular pressure alone (Table 2). MEDICAL Vascular

STATUS Disease

There is an association and intraocular pressure. there and

is an association high

blood

between blood IlJ.1t.38.t2.tt.17.ti7 In

between

pressure,”

ocular

although

pressure addition,

hypertension no association

to date has been found between glaucoma (i.e., visual field loss) and high blood pressure.1”.t7 Other diseases which are a manifestation of generalized disease such as atherosclerotic heart disease and cerebrovascular disease have no clear association with glaucoma, but they do carry the potential for compromise of the blood supply to the eye and this could contribute to the development of glaucoma. t7

vascular

GLAUCOMA

SCREENING

IN THE HEALTH

CARE SETTING TABLE

Rejkrral

Percentages for SpeciJc

169

3B

Abnormalities

in .Surqr

in the Health

Care Setting % referred

Referral

Vaughan

et al.

Not

l9577R

Horsley et al, 1958” Lasky et al. 1959 Brndor-Samuel \ I’;60 Packer et al. l&4”’ RlcDonald & Johnsos, Ross. 1968”’ Fair. 1972”

‘1

Spector et al, 1975” Robertson. 1977”’ Hammond & Begl~y, Steinmann et al, Levi 8r Schwartz.

1982” 1983

196jtq

1979”

-

stated

Visual field tonography

-

S B 25 mmHg Not stated S > 24 mmHg S 2 23.8 mmHg** S S 4.5 on scale S 2 25 mmHg mm > 24 mmHg asymmetry 2 4 mmHg S > 20 mmHg S > 24 mmHg** S 2 21 mmHg

-

“Cupped”

-

S < 4.0 on scale NCYI’ 2 24 mmHg asymmetry B 5 mmHg

No. screened

Other

Discs

IOP

Authors

criteria

-

-

-

C/D

-

> 0.5

Discs

Discs & IOP

-

-

2,415f

3.5

1,210 964 5,000 5,738t 10,090 1,724 2.396

2.5.8 IO.7 ,1.3 3.9 8.1 .i. 5 8.8

0.3 -

768 456 198(IOP) 188(discs) 554 770

-

area of pallor 3 30% asymm. 2 10% vertical bias, notching hemorrhage

IOP

-

-

-

-

13.5 2.6 10.6

8.0

-. -

15.5 2.5

8.7

2.1

;1hhreviations: S = Schiotz tonometer; MM = kIcE;ay Mary twometer; NC:T = non-contact tonometer; G = Goldmann tonomrt~r. *For studies in which referral rates were not stated, \,alues were calculated from authors’ data. able to be calculated from data fbr comparison purposes. **:\ctual IOP criteria differed. hut referral rate at 2 24 mmHg tSuhsct of larger sur\q.

.Ilban R$wd

Percentages for Specijic .Ibnormalities

Total Health care setting surveys (excluding ix\-i & Schwartz) Cbmmunity sur\.eys Ix1.i & Schwartz. 1983 Values *Only

jiom

Intraocular

Pressure

screened

Total

referred

2,285 1,188 35

(7.3%) (t.5%) (4.6%)

31,503 26.675 770

were calculated from available data, survcvs usin? quantitative criteria for disc

Table 9 shows the data for glaucoma screening studies which identified these diseases, particularly vascular hypertension. Most expressed their results in qualitative terms, hut the composite figures of those which had quantitative data show that the percentage of referral/detection for glaucoma or ocular hypertension in subjects with vascular dis-

Studies Cited in Table 3 Discs*

evaluation

‘Total

screened

I88 It,894 770

Total

refrrrrd

15 (8.0%) 580 (3.9%) 83 (10.8”/0)

included.

ease is more than 50% greater than in subjects with no vascular disease (P < 0.0001; see also Fig. 1). In our study (Table 2), the referral percentage was also higher in patients with vascular disease. This was seen overall and in referrals for abnormal intraocular pressure alone, but not in referrals for optic discs.

170

Surv Ophthalmol

28(3) November-December

1983

LEVI, SCHWARTZ

Diabetes Mellitus

also Fig. 1).

Diabetes mellitus has been implicated as a risk I() shows data factor for glaucoma., 7.7.17.23.38,47,73 Table for several screening studies which investigated the prevalence of glaucoma in diabetics. It can be seen in the composite figures that the referral rates for diabetics in these glaucoma screening studies is almost twice that for nondiabetics (P < 0.0001, see

This trend is also seen in our study where 16.0% of diabetics were referred compared to 12.9% of nondiabetics. Table 2 shows this in particular for those referred for increased intraocular pressure alone, and for increased intraocular pressure accompanied by abnormal discs, but not for optic discs alone.

TABLE Referral

Number Age screened

:1uthors L as k Y et al 1959’” Armaly, 19b2’

<44 <40

Packer et al, 1964”” Frydman et al, 1966’7 Kahn et al 1977:j7

644 -

Levi & Schwartz,

<40

1983

TOTAL *Includes

392 772 20,205 170

<44 only

those

studies

5

Percentages

Referred %

Age screened

265 a60

265 1,121

16.2 19.6

(43) (220)

0.9

(182)

40-59 45-64 52-64

5,515 25,197 1,465

7.1 2.7 20.2

(392) (680) (296)

260 365 265

3,728 21,791 1,475

8.5 4.2 25.2

(317) (915) (372)

9.4

(16)

4c-59

273

14.7

(40)

360

327

14.1

(291)

40-64

percentages

35,094

442 1,220

%

(n)

5.7 24.6

(25) (300)

3.9 9.8 16.7

4,354

could

260

28,707

be calculated

from

6.66

available

bv Sex*

Referred

(eyes)

referral

given

(1,744)

6

Perrentages

2,084 369 239

in which

4.97

by age were

Males screened

11.07 percentages

Referred

Females screened 342 1,720

(81) (36) (40)

3,270 702 531

(482)

6,565

by sex were

given

%

(eyes)

(n)

6.4 21.4

(22) (368)

3.2 8.7 11.7

(105) (61) (62)

9.41 or could

(618)

be calculated

from

data.

TABLE Referml

Authors Frydman et al, 1966’7 Coulehan et al, 1980’” Klein 8r Klein, 1981” Levi & Schwartz, 1983 TOTAL *Includes only available data.

studies

7

Percentages

bv Race*

Referred %

(n)

3,741 357 1,163 94

5.2 16.5 5.6 19.1

(195) (59) (65) (18)

63,452

(337)

72,635

in which

6.29 referral

percentages

Referred

Whites screened

Blacks screened

5,355 those

(n)

(43) (293)

:\uthors

available

%

14.0 12.5

TABLE

studies

screened

307 2,337

referral

only those

Age

45-64 40-59

Referral

*Includes

(n)

(17) (76)

in which

TOTI~L

%

Referred

Number

4.3 9.8

1.35

Coulehan et al, 1980”” Levi & Schwartz, 1983

Referred

Number

(n)

21,539

\Vallace & Love& 196g8” Kahn et al, 1977’” Klein 8; Klein, 1981”

b_yAge+

4,321 4,191 671

by race were given

%

(n)

2.5 3.4 2.9 12.4

( 1,586)

2.67 or could

(147) (122) (83)

( 1,938)

be calculated

from

(46) (1,913) data.

GLAUCOMA

SCREENING

Conclusions

IN

THE

HEALTH

CARE

the present time. Risk factors for the development of glaucoma include aging, being black, being male, and having a first-degree relative with glaucoma. Additionally, diabetes and vascular disease, including vascular hypertension, atherosclerotic heart disease and cerebrovascular disease, should be considered as risk factors. Since a health care setting usually contains a concentration of those who are at higher risk of developing glaucoma, it is recommended that this type of location be used more frequently to screen for glaucoma. More specifically, this could include the offices of primary care physicians, hospital outpatient

and Recommendations

.4lthough mass glaucoma screening surveys in the community are useful for glaucoma detection and public awareness, we suggest from this literature review and our own study that in order to better use our resources and maximize the detection of new glaucoma cases, the present approaches could be modified. LOCATION

OF

GLAUCOMA

It appears underutilized

that health care locations have been an settina for glaucoma screening up to

SCREENING

TABLE

ReftrrnlPercentaps.

or Glaucoma Family

8

Detection Percentages b_y Fami!,~ History* history

No family

glaucoma

Referred/detected

NO.

screened

.iuthors

171

SETTING

%

(11)

Becker et al, 1960” Paterson, 1966j7

110 76

5.5 25.0

(6) (19)

Ctameron, 1966” Perkins, 1974”’ Leighton, 1976”

100 305 187

17.0 32.8 9.1

(17) (100) (17)

55

20.0

Total screening studies from Table 1 (1951-83) Levi & Schwartz, TOTAL

%

-

-

454,260

5.6

715 454,975

(170)

Results for Authors Lasky

et al,

1959r’

Bengtsson, 1972”’ Leighton & Phillips, Bulpitt et al, 197.5” Kahn et al, 1977ss Klein

8r. Klein,

Levi & Schwartz,

TOTALt

Vascular Disease

l972r*

19814’ 1983

836 no “hypertensive diseases” 128 “hypertensive diseases” 1,644 11 normals, 11 LTG, 11 OAG 573 cohort of Framingham Heart Study

(91)

5.60

(25,484) were given or a family history

9

and GlauromalOcular

No. screened

(25,393)

12.7

*Includes only studies in which referral percentages, or glaucoma detection percentages, could he calculated from available data, for family history. Subjects wrre considered to have if the\ had a first-degree relative (parent, child, or sibling) with glaucoma.

TABLE

(11)

-

(11)

20.41

883

Referred/detected

No. screened

-

1983

history

Hypertension

Results

(in percentages

where

possible)**

3019 normal blood pressure 2335 vascular hypertension 348 with no vascular diseases* 422 with vascular diseases

9.9% referred (n = 83) 15.6% referred (n = 20) blood pressure and IOP correlated blood pressure and IOP correlated in LTG, OAG blood pressure and IOP correlated systohc blood pressure associated with ocular hypertension 2.1% with ocular hypertension (n = 63) 5.2% with ocular hypertension (n = 121) 11.8% referred (n = 41) 14.5% referred (n = 61)

vascular disease 2,885 no vascular disease 4,203

7.0% 4.4%

referred/detected referred/detected

Abbreviations: LTG = low tension glaucoma; OAG = open angle glaucoma. *Vascular hypertension, atherosclerotic heart disease, cerebrovascular disease. **For studies in which referral percentages were not stated, values were calculated from tTotals calculated from Lasky et al,42 Klein & Klein,‘” and Levi & Schwartz, 1983.

(n = (n =

authors’

202) 187)

data.

172

Surv Ophthalmol

28(3) November-December

1983

LEVI, SCHWARTZ

TABLE Studies Involving Diabetes

No. diabetics screened

Authors Lasky et al, 1959”’ Armstrong et al, 1960” Christiansson, 1961 I7 Becker, 197 1’ IOP discs Dorello 1972’” Levi & ‘Schwartz, 1983 TOTAL

IO

and Glaucoma

%

(n)

58 393 335

20.7 8.7 12.5

(12) (34) (42)

400 228

15.0 32.0 14.0

75

16.0

1,589

14.0

100 (eyes)

departments and other health care facilites containing a large elderly population or a large population of blacks; as well as facilities treating conditions such as diabetes or vascular disease. Such selective screening would maximize detection of new cases of glaucoma.H~“‘~~77Furthermore, it is important that physicians keep these risk factors in mind when examining patients. However, screening in a community setting should still play an important role. Screening in such a setting could be more effective if it were aimed at groups who have the risk factors as detailed above, i.e., aging, being black, being male, having a first-degree relative with glaucoma and a medical history of diabetes and vascular disease.

scopy

should

ideally

be

accompanied

by

tonom-

Referred %

(n)

906 280 -

10.0 3.6 -

(91) (10)

(60) (32) (32)

1,000 100 (eyes) -

18.0 18.0 -

(18) (18)

(12)

695

12.9

(901 \

(224)

2,981

for diabetics

7.61

I

(227)

were given or could be calculated

etry.“:’ However, given the reluctance ofmany physicians to perform tonometry, ophthalmoscopy could be the primary modality, serving as a convenient and inexpensive adjunct to present community tonometry programs. Advances in the methodology for screening by automatic analysis of photographs of the optic disc@ and the use of automatic perimetry” may still further improve our detection of glaucoma. Acknowledgments Thanks are given to John T. Harrington, M.D., and the medical, nursing and secretarial staff of General Medical Associates at New England Medical Center, Boston for their cooperation in this project. Judith Barton, M.S., provided statistical analysis, and Victoria R. Gibson, M.A., edited the manuscript.

OF SCREENING

The method used for screening is a secondary issue in this review, but it does emerge from the data presented in Tables 3 and 4 that ophthalmoscopy has been underutilized for glaucoma screening. This has occurred even though the value of a single tonometric reading is in doubt,‘6~2Q~“‘~34~60~~~~71 even though criteria for identifying suspicious discs have been better d~fined,2s.30~36~t’~64.6s~~’ and even though ophthalmoscopy would increase the number of cases detected since it uncovers more established disease.“l For glaucoma screening to be done in health care as we have recommended, physicians settings, could screen for glaucoma as part of their routine funduscopic examination. Since few subjects are found to have both abnormal intraocular pressure and disc abnormalities on screening, ophthalmo-

Data *

No. nondiabetics screened

Referred

*Includes only those studies in which referral percentages from available data.

METHODS

Screening Referral

References of elevated in1. Anderson DR, Hoskins HD: The management traocular pressure with normal optic discs and visual lields. Surv Ophthalmol 21:479, 489-493, 1977 study of glaucoma. 2. Armaly MI: The Des Moines population ImestOphthalmoi 1:61%628, 1962 3. Armstrong *JR, Daily RK, Dobson HL, Girard LJ: The incidence glaucomain diabetes mellitus. AmJ Ophthalmol50:5563, 1960 4. Bankes JLK, Perkins ES, Tsolakis S: BedCord Glaucoma Survey. Br MedJ 1:791-796, 1968 5. Bechetoille A, Aouchichc M, Hartani D: L’etude de Touggourt, une proposition pour le d’epistage de masse des glaucomes chronique par I’examen du disque optique. J Fr Ophthalmol 3~49%500, 1980 Becker B, Kolker AE, Roth FD: Glaucoma family study. Am J Ophthnlmol50:557-567, 1960 Becker B: Diabetes mellitus and primary open angle glaucoma. Am J Ophthalmol 71:1-16, 1971 Bellows RT, Bellows JG: Selective screening for glaucoma. Proc Inst Med Chgo 32:23-24, 1978 Bendor-Samuel JE, May W, Reed H: Routine tonometry in 5000 patients for detection of early glaucoma. BY Med J I :853855. 1960

of

GLAUCOMA SCREENING

IN THE HEALTH

CARE SETTING

.i:i.

i

1

ii.

if;. 57.

.X. 59 60. 61. 62. 63. 64.

65. lit,.

174

Surv Ophthalmol

28(3) November-December

1983

Otolaygol 81:OP 227-237, 1976 67. Schwartz B, Kcrn.J: Age, increased ocular and blood pressures, and retinal and disc lluorcsccin angiogram. Arch Ophthalmol 98:1980-1986, 1980 68. Schwartz.JT: Influence ofsmall systematic errors on the results or tonomctric screening. ilm J Ophthalmol 6(1:409-411, 1965 69. Shields MB: ‘l‘hc non-contact tonomcter. It’s value and limitations. Sun Ophthalmol 241211-219, 1980 70. Shiosc Y, Kawasc Y: Versatile investigations on NCI‘valur.,/~?t Reo Ctin OphthalmoI 74:96&971. 1980 71. Shiosr Y, Komuro K, Itoh Tet al: New system Tar mass scrreningofglaucoma, as part ofautomated multiphasic health trsting services. &I J 0phthalmo/25:16&177, 1981 72. Spector R, Lightfoote .JB, Cohen P. Chylack 1.X’ .Jr: Should tonomctry screening be done by technicians instead of physicians? Arch lnt Med 1%: 1260-1262, 1975 73. Stirk N, Hosch L$‘: Ein Bctrag zum Problem: Glaukom und Diabetes Mcllitus. Klin Monatsbl Augcnheiikd 160:324-326, 1972 74. Steinmann WC, Licht E, Sicgler JE, Nichols CW: Screening for glaucoma by general medical residents. Arch Int Med 1422:785786, 1982 75. Stromberg U: Ocular hypertension: frequency, course and rclation to other disorders occuring in glaucoma, as seen from mass survey of all inhabitants over forty years of’ age in a Swedish town. Acta Ophthalmol (suppl) 69:1-75, 1962 76. l‘aubenhaus IJ: Glaucoma screening in Brookline. Sight Sari Rezl 31:1&22, 1961

LEVI, SCHWARTZ 77. US Department ofHealth, Education and Welfare: Principlesand Procedures in the Evaluation of.Screeningfor II Disease. Washington DC, US Government Printing Oflice, 1961 78. \‘aughan DG: Glaucoma detection in private practice and hospital. Sight Sat, Rer’ 27:145-148. 1957 79. \valkcr i%‘%f, Vodden \‘&I: Birmingham Glaucoma Survey 1963-1965. Interim Report. in Hunt LB (cd): Glaucoma: b&demiologs. Ear!r Diagnosis and Some Aspects of Treatment. London, E and S Livingston, 1966, pp 4-l 1 80. \~allacc .J, Love11 HG: Glaucoma and intraocular pressure in ,Jamaica. Am J Ophthalmol67:93-100. 1967 81. W’ilrnski .JT. Podos, SM: Prognostic parameters in primary oprn angled glaucoma. in Clark M’B [cd): Svmposium on Glaucoma. St Louis, CV Tviosby, 1975, pp 7-30 82. i$‘olpaw B,J* Sherman AM’: The Cleveland Glaucoma Survey. Si~qhtSW Ret’ 24: 139-144, 1954 83. Zcller RM’, Christensen I.: Routine tonomctry as a part of the physical examination. JAMA 154:1343-1345, 1954

Supported in part by a grant from Merck Sharp & Dohme. Reprint requests should be addressed to Bernard Schwartz, M.D., Ph.D., Dept. OlOphthalmology, Tufts-New England Medical Center. 171 Harrison Ave., Boston, MA 02111.