Primary Open-Angle Glaucoma Preferred Practice Pattern®

AMERICAN ACADEMY OF OPHTHALMOLOGY® Protecting Sight. Empowering Lives.® Primary Open-Angle Glaucoma Preferred Practice Pattern® Secretary for Quality of Care Timothy W. Olsen, MD Academy Staff Ali Al-Rajhi, PhD, MPH Andre Ambrus, MLIS Meghan Daly Flora C. Lum, MD Medical Editor: Susan Garratt Approved by: Board of Trustees September 12, 2020 Copyright © 2020 American Academy of Ophthalmology® All rights reserved AMERICAN ACADEMY OF OPHTHALMOLOGY and PREFERRED PRACTICE PATTERN are registered trademarks of the American Academy of Ophthalmology. All other trademarks are the property of their respective owners. Preferred Practice Pattern® guidelines are developed by the Academy's H. Dunbar Hoskins Jr., MD Center for Quality Eye Care without any external financial support. Authors and reviewers of the guidelines are volunteers and do not receive any financial compensation for their contributions to the documents. The guidelines are externally reviewed by experts and stakeholders before publication. GLAUCOMA PREFERRED PRACTICE PATTERN® DEVELOPMENT PROCESS AND PARTICIPANTS The Glaucoma Preferred Practice Pattern® Panel members wrote the Primary Open-Angle Glaucoma Preferred Practice Pattern® guidelines (PPP). The PPP Panel members discussed and reviewed successive drafts of the document, meeting in person twice and conducting other review by e-mail discussion, to develop a consensus over the final version of the document. Glaucoma Preferred Practice Pattern Panel 2019-2020 Steven J. Gedde, MD, Chair Kateki Vinod, MD Martha M. Wright, MD, American Glaucoma Society Representative Kelly W. Muir, MD John T. Lind, MD Philip P. Chen, MD Tianjing Li, MD, MHS, PhD, Consultant, Cochrane Eyes and Vision Project Steven L. Mansberger, MD, MPH, Methodologist We thank our partners, the Cochrane Eyes and Vision US Satellite ([email protected]), for identifying reliable systematic reviews that we cite and discuss in support of the PPP recommendations. The Preferred Practice Patterns Committee members reviewed and discussed the document during a meeting in May 2020. The document was edited in response to the discussion and comments. Preferred Practice Patterns Committee 2020 Roy S. Chuck, MD, PhD, Chair Steven P. Dunn, MD Christina J. Flaxel, MD Steven J. Gedde, MD Francis S. Mah, MD Kevin M. Miller, MD James P. Tweeten, MD David K. Wallace, MD, MPH David C. Musch, PhD, MPH, Methodologist The Primary Open-Angle Glaucoma PPP was then sent for review to additional internal and external groups and individuals in June 2020. All those who returned comments were required to provide disclosure of relevant relationships with industry to have their comments considered (indicated with an asterisk below). Members of the PPP Panel reviewed and discussed these comments and determined revisions to the document. Academy Reviewers Board of Trustees and Committee of Secretaries* Council* General Counsel* Ophthalmic Technology Assessment Committee Glaucoma Panel* Basic and Clinical Science Course Section 10 Subcommittee Practicing Ophthalmologists Advisory Committee for Education Invited Reviewers American College of Surgeons American Glaucoma Society American Ophthalmological Society Association for Research in Vision and Ophthalmology Association of University Professors in Ophthalmology* Consumer Reports Health Choices Canadian Ophthalmological Society* European Glaucoma Society* International Council of Ophthalmology International Society of Glaucoma Surgery International Society of Refractive Surgery National Eye Institute* National Medical Association, Section on Ophthalmology North American Neuro-Ophthalmology Society Outpatient Ophthalmic Surgery Society World Glaucoma Association* Women in Ophthalmology* Wallace L.M. Alward, MD* Ta Chen Chang, MD FINANCIAL DISCLOSURES In compliance with the Council of Medical Specialty Societies’ Code for Interactions with Companies (available at https://cmss.org/code-signers-pdf/), relevant relationships with industry are listed. The Academy has Relationship with Industry Procedures to comply with the Code (available at www.aao.org/about-preferred-practice-patterns). A majority (57%) of the members of the Glaucoma Preferred Practice Pattern Panel 2019-2020 had no related financial relationship to disclose. Glaucoma Preferred Practice Pattern Panel 2019-2020 Steven J. Gedde, MD: No financial relationships to disclose Philip P. Chen, MD: Allergan—Consultant/Advisor John T. Lind, MD: Aerie Pharmaceuticals, Allergan—Consultant/Advisor; Aerie Pharmaceuticals, Allergan—Lecture Fees, Perrigo—Grant Support Kelly W. Muir, MD: No financial relationships to disclose Kateki Vinod, MD: No financial relationships to disclose Martha M. Wright, MD: No financial relationships to disclose Tianjing Li, MD, MHS, PhD: No financial relationships to disclose Steven L. Mansberger, MD, MPH: Allergan—Grant Support Preferred Practice Patterns Committee 2020 Roy S. Chuck, MD, PhD, Chair: No financial relationships to disclose Steven P. Dunn, MD: No financial relationships to disclose Christina J. Flaxel, MD: No financial relationships to disclose Steven J. Gedde, MD: No financial relationships to disclose Francis S. Mah, MD: Abbott Medical Optics Inc., Aerie Pharmaceuticals, Alcon Laboratories, Allergan, Bausch + Lomb, EyePoint, Kala Pharmaceuticals, Novartis Pharmaceuticals, Ocular Science, Ocular Therapeutix, Omeros Corporation, PolyActiva—Consultant/Advisor; Abbott Medical Optics Inc., Bausch + Lomb, Novartis Pharmaceuticals—Lecture Fees; Abbott Medical Optics Inc., Ocular Therapeutix—Grant Support; Ocular Science—Equity Owner Kevin M. Miller, MD: Alcon Laboratories, Johnson & Johnson Vision—Consultant/Advisor James P. Tweeten, MD: No financial relationships to disclose David K. Wallace, MD, MPH: No financial relationships to disclose David S. Musch, PhD, MPH, Methodologist: No financial relationships to disclose Secretary for Quality of Care Timothy W. Olsen, MD: No financial relationships to disclose Academy Staff Ali Al-Rajhi, PhD, MPH: No financial relationships to disclose Andre Ambrus, MLIS: No financial relationships to disclose Meghan Daly: No financial relationships to disclose Flora C. Lum, MD: No financial relationships to disclose Susan Garratt: No financial relationships to disclose The disclosures of relevant relationships to industry of other reviewers of the document from January to October 2020 are available online at www.aao.org/ppp. TABLE OF CONTENTSOBJECTIVES OF PREFERRED PRACTICE PATTERN GUIDELINES P77METHODS AND KEY TO RATINGS P78HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE P79INTRODUCTION P80Disease Definition P80Clinical Findings Characteristic of Primary Open-Angle Glaucoma P80Patient Population P81Clinical Objectives P81BACKGROUND P81Prevalence P81Risk Factors P83Intraocular Pressure P83Age P86Family History P86Race or Ethnicity P86Genetic Factors P86Central Corneal Thickness P86Ocular Perfusion Pressure P87Type 2 Diabetes Mellitus P88Myopia P88Other Factors P88POPULATION SCREENING FOR GLAUCOMA P89CARE PROCESS P90Patient Outcome Criteria P90Diagnosis P90History P90Evaluation of Visual Function P91Physical Examination P91Diagnostic Testing P93Differential Diagnosis P95Management P96Goals P96Target Intraocular Pressure P96Choice of Therapy P97Follow-up Evaluation P113Risk Factors for Progression P114Adjustment of Therapy P115Provider and Setting P115Counseling and Referral P116Socioeconomic Considerations P116APPENDIX 1. QUALITY OF OPHTHALMIC CARE CORE CRITERIA P119APPENDIX 2. INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS (ICD) CODES P121APPENDIX 3. LITERATURE SEARCHES FOR THIS PPP P122RELATED ACADEMY MATERIALS P123REFERENCES P124 Primary Open-Angle Glaucoma Preferred Practice Pattern® Background: Primary open-angle glaucoma (POAG) is a chronic, progressive ocular disease causing loss of the optic nerve rim and retinal nerve fiber layer (RNFL) with associated visual field defects. The anterior chamber angle is open, and the disease is generally bilateral. Risk factors for POAG include older age, African race or Latino/Hispanic ethnicity, elevated intraocular pressure (IOP), family history of glaucoma, lower ocular perfusion pressure, type 2 diabetes mellitus, and thin central cornea. It is estimated that 53 million people in the world have POAG in 2020 with a prevalence of 3.0% in the population aged 40 to 80 years. Rationale for Treatment: Clinical trials have shown that lowering IOP reduces the risk of developing POAG and slows the progression of the disease. Medical, laser, and incisional surgical approaches exist to effectively lower IOP. Early diagnosis and treatment generally prevent visual disability. Care Process: The goals of managing patients with POAG are to control IOP in a target range and to prevent progressive visual field and optic nerve/RNFL damage in order to preserve visual function and quality of life. The initial glaucoma evaluation includes all components of the comprehensive adult medical evaluation focusing on those elements that specifically pertain to the diagnosis and management of POAG. Important diagnostic testing includes central corneal thickness measurement, visual field evaluation, and imaging of the optic nerve head, RNFL and macula. The relative risks and benefits of treatment with medications, laser therapy, or incisional surgery should be discussed with the patient prior to its initiation. The adequacy of treatment is determined during follow-up by regular assessment of the optic nerve appearance and quantitative evaluation with visual field testing and imaging of the optic nerve head, RNFL and macula. OBJECTIVES OF PREFERRED PRACTICE PATTERN® GUIDELINES As a service to its members and the public, the American Academy of Ophthalmology has developed a series of Preferred Practice Pattern® guidelines that identify characteristics and components of quality eye care. Appendix 1 describes the core criteria of quality eye care. The Preferred Practice Pattern® guidelines are based on the best available scientific data as interpreted by panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted clinical trials are available, the data are particularly persuasive and provide clear guidance. In other instances, the panels have to rely on their collective judgment and evaluation of available evidence. These documents provide guidance for the pattern of practice, not for the care of a particular individual. While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all patients. Adherence to these PPPs will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients’ needs in different ways. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice. Preferred Practice Pattern® guidelines are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein. References to certain drugs, instruments, and other products are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard, that reflect indications not included in approved U.S. Food and Drug Administration (FDA) labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate patient consent in compliance with applicable law. Innovation in medicine is essential to ensure the future health of the American public, and the Academy encourages the development of new diagnostic and therapeutic methods that will improve eye care. It is essential to recognize that true medical excellence is achieved only when the patients’ needs are the foremost consideration. All Preferred Practice Pattern® guidelines are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all PPPs are current, each is valid for 5 years from the “approved by” date unless superseded by a revision. Preferred Practice Pattern guidelines are funded by the Academy without commercial support. Authors and reviewers of PPPs are volunteers and do not receive any financial compensation for their contributions to the documents. The PPPs are externally reviewed by experts and stakeholders, including consumer representatives, before publication. The PPPs are developed in compliance with the Council of Medical Specialty Societies’ Code for Interactions with Companies. The Academy has Relationship with Industry Procedures (available at www.aao.org/about-preferred-practice-patterns) to comply with the Code. Appendix 2 contains the International Statistical Classification of Diseases and Related Health Problems (ICD) codes for the disease entities that this PPP covers. The intended users of the Primary Open-Angle Glaucoma PPP are ophthalmologists. METHODS AND KEY TO RATINGS Preferred Practice Pattern® guidelines should be clinically relevant and specific enough to provide useful information to practitioners. Where evidence exists to support a recommendation for care, the recommendation should be given an explicit rating that shows the strength of evidence. To accomplish these aims, methods from the Scottish Intercollegiate Guideline Network1Scottish Intercollegiate Guidelines Network Annex B: Key to evidence statements and grades of recommendations. SIGN 50: A guideline developer's handbook.2008 edition, revised 2011. SIGN, Edinburgh2015Available at: www.sign.ac.ukDate accessed: November , 2020Google Scholar (SIGN) and the Grading of Recommendations Assessment, Development and Evaluation2Guyatt GH Oxman AD Vist GE et al.GRADE: An emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar (GRADE) group are used. GRADE is a systematic approach to grading the strength of the total body of evidence that is available to support recommendations on a specific clinical management issue. Organizations that have adopted GRADE include SIGN, the World Health Organization, the Agency for Healthcare Research and Policy, and the American College of Physicians.3GRADE working group Organizations that have endorsed or that are using GRADE.Available at: www.gradeworkinggroup.org/Date accessed: November , 2020Google Scholar♦All studies used to form a recommendation for care are graded for strength of evidence individually, and that grade is listed with the study citation.♦Tabled 1I++High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of biasI+Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of biasI-Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of biasHigh-quality systematic reviews of case-control or cohort studiesHigh-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causalII+Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causalII-Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causalIIINonanalytic studies (e.g., case reports, case series) Open table in a new tab ♦Tabled 1Good qualityFurther research is very unlikely to change our confidence in the estimate of effectModerate qualityFurther research is likely to have an important impact on our confidence in the estimate of effect and may change the estimateInsufficient qualityFurther research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate Any estimate of effect is very uncertain Open table in a new tab ♦Tabled 1Strong recommendationUsed when the desirable effects of an intervention clearly outweigh the undesirable effects or clearly do notDiscretionary recommendationUsed when the trade-offs are less certain—either because of low-quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced Open table in a new tab ♦The Highlighted Findings and Recommendations for Care section lists points determined by the PPP Panel to be of particular importance to vision and quality of life outcomes.♦All recommendations for care in this PPP were rated using the system described above. Ratings are embedded throughout the PPP main text in italics.♦Literature searches to update the PPP were undertaken in March 2019 and June 2020 in the PubMed and Cochrane databases. Complete details of the literature searches are available in Appendix 3. HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE Established risk factors for primary open-angle glaucoma (POAG) include older age, African race or Latino/Hispanic ethnicity, elevated intraocular pressure (IOP), family history of glaucoma, low ocular perfusion pressure, type 2 diabetes mellitus, myopia, and thin central cornea. Primary open-angle glaucoma patients often have untreated IOP consistently within the normal range (i.e., normal tension glaucoma). Lowering pressure in these patients is beneficial. Characteristic clinical features of POAG include an open angle on gonioscopy, and glaucomatous optic nerve head (ONH) and retinal nerve fiber layer (RNFL)/macula imaging changes that usually are associated with typical glaucomatous visual field defects. Computer-based imaging and stereoscopic photography provide different and complementary information about optic nerve status. Adjusting computerized visual field programs (24 degrees, 30 degrees, 10 degrees) and stimulus size (III, V) can aid in detecting and monitoring progressive visual field loss. Clinical trials have shown that lowering IOP reduces the risk of developing POAG and slows the progression of POAG. Effective medical, laser, and incisional surgical approaches exist for lowering IOP. A reasonable initial treatment goal in a POAG patient is to reduce IOP 20% to 30% below baseline and to adjust up or down as indicated by disease course and severity. Primary open-angle glaucoma (POAG) is a chronic, progressive optic neuropathy in adults in which there is a characteristic acquired atrophy of the optic nerve and loss of retinal ganglion cells and their axons. This condition is associated with an open anterior chamber angle by gonioscopy. Primary open-angle glaucoma is a potentially blinding eye disease, but early diagnosis and treatment can generally prevent visual disability. Primary open-angle glaucoma is a chronic ocular disease process that is progressive, generally bilateral, but often asymmetric.4Jonas JB Budde WM Panda-Jonas S Ophthalmoscopic evaluation of the optic nerve head.Surv Ophthalmol. 1999; 43: 293-320Abstract Full Text Full Text PDF PubMed Scopus (439) Google Scholar It is associated with the following characteristics:♦Evidence of optic nerve damage from either, or both, of the following:♦Optic disc or retinal nerve fiber layer (RNFL) structural abnormalities■Diffuse or focal narrowing, or notching, of the optic disc rim, especially at the inferior or superior poles, which forms the basis for the ISNT rule5Morgan JE Bourtsoukli I Rajkumar KN et al.The accuracy of the inferior>superior>nasal>temporal neuroretinal rim area rule for diagnosing glaucomatous optic disc damage.Ophthalmology. 2012; 119: 723-730Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar (see subsection on optic nerve head and retinal nerve fiber layer clinical examination in Physical Examination section)■Progressive narrowing of the neuroretinal rim with an associated increase in cupping of the optic disc■Diffuse or localized thinning of the parapapillary RNFL, especially at the inferior or superior poles. (Highly myopic individuals without glaucoma may have diffusely thin RNFL.)■Optic disc hemorrhages involving the disc rim, parapapillary RNFL, or lamina cribrosa■Optic disc neural rim asymmetry of the two eyes consistent with loss of neural tissue■Beta-zone parapapillary atrophy■Thinning of the RNFL and/or macula on imaging♦Reliable and reproducible visual field abnormality■Visual field damage consistent with RNFL damage (e.g., nasal step, arcuate field defect, or paracentral depression in clusters of test sites)6Foster PJ Buhrmann R Quigley HA Johnson GJ The definition and classification of glaucoma in prevalence surveys.Br J Ophthalmol. 2002; 86: 238-242Crossref PubMed Scopus (1335) Google Scholar■Visual field loss across the horizontal midline in one hemifield that exceeds loss in the opposite hemifield (in early/moderate cases)■Absence of other known explanations (e.g., optic disc drusen, optic nerve pit, retinal or neurological pathology)♦Adult onset♦Open anterior chamber angles♦Absence of other known explanations (i.e., secondary glaucoma) for progressive glaucomatous optic nerve change (e.g., pigment dispersion syndrome, pseudoexfoliation syndrome, uveitis, trauma, and corticosteroid use) Primary open-angle glaucoma represents a spectrum of disease in adults in which the susceptibility of the optic nerve to damage varies among patients. Although many patients with POAG present with elevated IOP, nearly 40% of those with otherwise characteristic POAG may not have elevated IOP measurements during office hours.7Dielemans I Vingerling JR Wolfs RC et al.The prevalence of primary open-angle glaucoma in a population-based study in the Netherlands: The Rotterdam study.Ophthalmology. 1994; 101: 1851-1855Abstract Full Text PDF PubMed Google Scholar The vast majority of patients with POAG have disc changes or disc and visual field changes,8Kass MA Heuer DK Higginbotham EJ et al.The ocular hypertension treatment study: A randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma.Arch Ophthalmol. 2002; 120 (discussion 829-730.): 701-713Crossref PubMed Google Scholar but there are cases where early visual field changes may develop before there are detectable changes to the optic nerve. The severity of glaucoma damage can be estimated according to the following categories:♦Mild: Definite optic disc, RNFL, or macular imaging abnormalities consistent with glaucoma as detailed above and a normal visual field as tested with standard automated perimetry (SAP)♦Moderate: Definite optic disc, RNFL, or macular imaging abnormalities consistent with glaucoma as detailed above, and visual field abnormalities in one hemifield that are not within 5 degrees of fixation♦Severe: Definite optic disc, RNFL, or macular imaging abnormalities consistent with glaucoma as detailed above, and visual field abnormalities in both hemifields and/or loss within 5 degrees of fixation in at least one hemifield as tested with SAP♦Indeterminate: Definite optic disc, RNFL, or macular imaging abnormalities consistent with glaucoma as detailed above, inability of patient to perform visual field testing, unreliable/uninterpretable visual field test results, or visual fields not yet performed The patient population consists of adults with open anterior chamber angles and demonstrated optic nerve or RNFL damage, and/or visual field loss. ♦Document the status of the optic nerve structure at baseline by clinical evaluation and imaging, and document visual function by visual field testing♦Estimate an IOP below which further optic nerve damage is unlikely to occur (see Target Intraocular Pressure subsection in the Care Process section)♦Perform and document gonioscopy♦Attempt to maintain IOP at or below a defined target level by initiating appropriate medical and/or surgical intervention(s) after discussing the options with the patient♦Monitor the structure and function of the optic nerve for further damage and adjust the target IOP to a lower level if deterioration occurs♦Minimize the side effects of treatment and their impact on the patient's vision, general health, and quality of life♦Educate and involve the patient and appropriate family members/caregivers in the management of the disease♦Maintain quality of vision and preserve quality of life Primary open-angle glaucoma is a significant public health problem.9Kapetanakis VV Chan MP Foster PJ et al.Global variations and time trends in the prevalence of primary open angle glaucoma (POAG): A systematic review and meta-analysis.Br J Ophthalmol. 2016; 100: 86-93Crossref PubMed Google Scholar, 10Tham YC Li X Wong TY et al.Global prevalence of glaucoma and projections of glaucoma burden through 2040: A systematic review and meta-analysis.Ophthalmology. 2014; 121: 2081-2090Abstract Full Text Full Text PDF PubMed Scopus (1754) Google Scholar, 11Quigley HA Broman AT The number of people with glaucoma worldwide in 2010 and 2020.Br J Ophthalmol. 2006; 90: 262-267Crossref PubMed Scopus (4233) Google Scholar, 12Klein BE Klein R Projected prevalences of age-related eye diseases.Invest Ophthalmol Vis Sci. 2013; 54: ORSF14-ORSF17Crossref PubMed Scopus (0) Google Scholar, 13Vajaranant TS Wu S Torres M Varma R The changing face of primary open-angle glaucoma in the United States: Demographic and geographic changes from 2011 to 2050.Am J Ophthalmol. 2012; 154: 303-314Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 14Friedman DS Wolfs RC O'Colmain BJ et al.Eye diseases prevalence research group. Prevalence of open-angle glaucoma among adults in the United States.Arch Ophthalmol. 2004; 122: 532-538Crossref PubMed Scopus (629) Google Scholar, 15Sommer A Tielsch JM Katz J et al.Racial differences in the cause-specific prevalence of blindness in East Baltimore.N Engl J Med. 1991; 325: 1412-1417Crossref PubMed Google Scholar, 16Varma R Ying-Lai M Francis BA et al.Los Angeles Latino eye study group. Prevalence of open-angle glaucoma and ocular hypertension in Latinos: The Los Angeles Latino eye study.Ophthalmology. 2004; 111: 1439-1448Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 17Stein JD Kim DS Niziol LM et al.Differences in rates of glaucoma among Asian Americans and other racial groups, and among various Asian ethnic groups.Ophthalmology. 2011; 118: 1031-1037Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar It is estimated that 76 million people in the world have glaucoma in the year 2020.10Tham YC Li X Wong TY et al.Global prevalence of glaucoma and projections of glaucoma burden through 2040: A systematic review and meta-analysis.Ophthalmology. 2014; 121: 2081-2090Abstract Full Text Full Text PDF PubMed Scopus (1754) Google Scholar Glaucoma (both open-angle and angle-closure) is the second leading cause of blindness worldwide.11Quigley HA Broman AT The number of people with glaucoma worldwide in 2010 and 2020.Br J Ophthalmol. 2006; 90: 262-267Crossref PubMed Scopus (4233) Google Scholar Overall, the prevalence of POAG for adults aged 40 and older was estimated to be about 3.05% in 2013.10Tham YC Li X Wong TY et al.Global prevalence of glaucoma and projections of glaucoma burden through 2040: A systematic review and meta-analysis.Ophthalmology. 2014; 121: 2081-2090Abstract Full Text Full Text PDF PubMed Scopus (1754) Google Scholar Prevalence studies suggest that POAG will increase by 50% worldwide from 52.7 million in 2020 to 79.8 million in 2040 as the population ages,10Tham YC Li X Wong TY et al.Global prevalence of glaucoma and projections of glaucoma burden through 2040: A systematic review and meta-analysis.Ophthalmology. 2014; 121: 2081-2090Abstract Full Text Full Text PDF PubMed Scopus (1754) Google Scholar and will disproportionally affect African and Asian countries.9Kapetanakis VV Chan MP Foster PJ et al.Global variations and time trends in the prevalence of primary open angle glaucoma (POAG): A systematic review and meta-analysis.Br J Ophthalmol. 2016; 100: 86-93Crossref PubMed Google Scholar, 10Tham YC Li X Wong TY et al.Global prevalence of glaucoma and projections of glaucoma burden through 2040: A systematic review and meta-analysis.Ophthalmology. 2014; 121: 2081-2090Abstract Full Text Full Text PDF PubMed Scopus (1754) Google Scholar, 12Klein BE Klein R Projected prevalences of age-related eye diseases.Invest Ophthalmol Vis Sci. 2013; 54: ORSF14-ORSF17Crossref PubMed Scopus (0) Google Scholar, 13Vajaranant TS Wu S Torres M Varma R The changing face of primary open-angle glaucoma in the United States: Demographic and geographic changes from 2011 to 2050.Am J Ophthalmol. 2012; 154: 303-314Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar Large differences exist in the prevalence of glaucoma among different ethnoracial groups (see Table 1 and Figure 1). Overall, there appears to be a threefold higher prevalence of open-angle glaucoma (OAG) in African Americans relative to non-Hispanic whites in the United States.14Friedman DS Wo