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  • Nature, Nurture, Neighborhood, Network, and Glaucoma


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    Anne Louise Coleman, MD, PhD, delivered the American Glaucoma Society Subspecialty Day Lecture, “Nature, Nurture, Neighborhood, Network, and Glaucoma,” as part of Friday’s Glaucoma Subspecialty Day, discussing the non-IOP risk factors for glaucoma.

    IOP does not equal glaucoma. Although IOP is a risk factor for glaucoma, it is one of many and not the sole contributor to glaucoma, said Dr. Coleman. Many patients who report good IOP still have conditions that may be associated with the disease, such as frequent falls, recurrent anxiety and depression, and sleep/waking disorders.

    Nature: genetic risk factors. Glaucoma has been linked to a single defect in one of three genes: myolicin, optineurin, and TANK-binding kinase 1. However, only 5% of glaucoma cases have been linked to these single-gene defects. Research from the GLAUGEN and NEIGHBOR studies have found a strong association between genetic risk scores and primary open-angle glaucoma (POAG).1

    Nurture: lifestyle risk factors. Since genetics play a relatively small role in glaucoma risk, Dr. Coleman outlined other factors that have a larger effect in reducing or increasing the risk. 

    Reduced risk:

    • Diet: Adequate amounts of fruits and vegetables, as well as omega-3 fatty acid intake2
    • Caffeinated tea (no clear effect of coffee on risk)
    • Exercise: 150 minutes of moderate exercise per week3

    Potential reduced risk

    • Marijuana use: Short-term IOP-lowering effects (3-4 hours) occur in about 60% to 65% of patients4

    Increased risk

    • Smoking5
    • Alcohol consumption6
    • Salt intake (in patients taking antihypertensive medicine)

    Neighborhood: built-in risk factors. Studies have shown that increased risk of glaucoma has been linked to air pollution (higher PM2.5 levels),7 as well as cockroach infestations and mildew. Higher rates of social vulnerability cause external stresses on human health, which manifest as diseases and conditions such as glaucoma.

    Network: access-to-care risk factors. Finally, access to care causes wide disparities in rates of glaucoma screening, diagnosis, and treatment:

      • Disparities by region: Lack of glaucoma subspecialists in rural areas leads to longer traveling distances to see a glaucoma physician, adding to the likelihood of surgery.
      • Disparities by insurance coverage: Medicaid recipients have lower rates of glaucoma testing than patients with commercial insurance, regardless of race.8
      • Disparities by race/ethnicity: Black and Hispanic patients have lower rates of glaucoma tests and consultations than non-Hispanic Whites.9
      • Disparities by health access: In one study, White and Black patients had equal testing and consultation rates. While the White patients had more surgeries, rates of mean deviation change were equal, indicating that better access leads to similar visual field progression.10

    The dangers of siloing risk factors. “Research tends to occur in silos,” said Dr. Coleman. Risk factors are studied in separate sets, but, as she noted, “risk factors are not acting alone—they’re acting together.” She mentioned that while myopia is a general risk factor for POAG, it increases the risk more among Black and Hispanic patients than in other groups.

    Look at social determinants of health. Dr. Coleman emphasized the need to put all the pieces together and then add in social determinants of health (SDOH), which are shaped by money, power, and access to resources. Racism is a public health issue affecting all aspects of SDOH and should not be overlooked when glaucoma specialists consider their whole patient population.

    —Stephanie Leveene, ELS

    1 Fan B et al. JAMA Ophthalmol. 2019:137(10):1190-1194.
    2 Wang S et al. Curr Eye Res. 2013;38(10):1049-1056.
    3 Meier N et al. Med Sci Sports Exerc. 2018;50:2253-2258.
    4 Green K. Arch Ophthalmol. 1998;116:1433-1437.
    5 Law S et al. Eye (Lond). 2018;32:716-725.
    6 Lamparter J et al. PLOS One. 2018;13:e0197682.
    7 Chua S et al. Invest Ophthalmol Vis Sci. 2019;60:4915-4923.
    8 Elam A et al. Ophthalmology. 2017;124:1442-1448.
    9 Halawa O et al. Ophthalmology. 2022;129:397-405.
    10 Melchior B et al. Br J Ophthalmol. 2022;106:229-233.

    Financial disclosures: Dr. Coleman: None

    Read more news about Subspecialty Day and AAO 2022.